Clinical Auditor

Job Summary

The Delegation Oversight Utilization Management team at Blue Shield Of Ca is responsible for the organization, tracking, and data entry of IPA Utilization Management audits, issues, complaints, and monitoring. This role requires identifying root causes of problems and maintaining monthly reporting to track and compare patterns of delegated entities.

Key Responsibilities

• Oversee policy and procedure reviews and complete limited and less complex full desk or onsite Pre-delegation, Annual, or follow-up audits/assessments of delegated entities, including vendors, in support of regulatory and NCQA requirements.
• Act as the auditor in charge on small and less complex audits, with supervision, of Sr. management and other delegated non-clinical areas through to corrective action plan oversight.
• Research, investigate, and oversee delegated entity's compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
• Collaborate on regulatory audits, findings responses, or enforcements by regulatory agencies.
• Responsible to write Corrective Action Plans and comprehensive summaries.
• Knowledge of DMHC, DHCS, CMS, Title 22 CCR, Title 28, Title 42, and Medi-Cal, Medicare processing guidelines.
• Ability to effectively communicate with internal and external associates.
• Responsible for reviewing criteria on denial letters.
• Responsible to handle multiple audits and able to prioritize workflow.

Requirements

• Current CA LVN License.
• Bachelors of Science in Nursing or advanced degree preferred.
• Requires at least 3 years of prior relevant experience in auditing of claims, credentialing, or recredentialing.
• Experience in auditing utilization management or prior out-patient authorization review preferred.
• Desired knowledge of accreditation entities and their requirements.
• Ability to work independently.
• Excellent verbal and written communication skills and interpersonal skills.
• Computer ease & literacy with Word, Excel, Power Point Skills.