Quality Assurance Compliance Analyst - Remote CA

About the role

As a Quality Assurance Compliance Analyst at Gainwell, you will support quality and compliance activities across healthcare operations for the Medi-Cal account. You will review claims and operational processes, analyze data to identify quality trends and potential issues, and help ensure work is completed accurately and in accordance with established policies, regulatory requirements, and organizational standards. You will partner with claims, clinical, compliance, and operational teams to identify opportunities for improvement and strengthen overall quality and performance.

Responsibilities

• Conduct quality reviews and audits of healthcare claims and operational processes to evaluate accuracy, completeness, and compliance with established policies, procedures, and regulatory requirements.
• Analyze claims data to identify trends, anomalies, coding errors, quality issues, and opportunities for improvement.
• Review claims, denials, appeals, provider enrollment, and related operational activities to validate data accuracy and identify potential compliance or quality concerns.
• Document audit findings, maintain appropriate audit trails, analyze quality metrics, and communicate findings to operational and non-technical stakeholders.
• Participate in root-cause analysis and recommend corrective actions and process improvements based on audit findings and identified trends.
• Support compliance and regulatory reporting, internal and external audits, and quality improvement initiatives in collaboration with claims, clinical, compliance, and operational teams.

Requirements

• High school diploma or GED required; bachelor’s degree or equivalent professional experience preferred.
• Three or more years of experience in quality assurance, compliance, auditing, healthcare operations, claims, or a related field.
• Experience with healthcare claims adjudication, claims validation, denials, appeals, billing, or related healthcare operational processes.
• Knowledge of common claims quality issues, coding errors, and healthcare quality or compliance requirements.
• Familiarity with Medicaid or Medi-Cal operations and regulatory requirements, including DHCS or other applicable state regulatory or accreditation requirements, preferred.
• Experience analyzing data, identifying trends, conducting root-cause analysis, and supporting process improvement initiatives.
• Experience maintaining quality documentation, audit findings, and audit trails.
• Knowledge of systems such as EDMS, NICE CXone, or MMIS is a plus.
• Strong analytical, problem-solving, organizational, and communication skills with excellent attention to detail.

Schedule

This position is primarily remote, with occasional in-office requirements at our West Sacramento, CA office based on business needs. Candidates must reside in California and be able to report to the West Sacramento office as needed. Travel requirements are approximately 0–10%.

Pay

The pay range for this position is $53,900.00 - $77,000.00 per year; base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience.

Benefits

All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also offer a variety of leadership and technical development academies to help build your skills and capabilities.