Compliance Audit Professional

2 days ago


Long Beach CA, United States Blue Shield of California Full time

Key Responsibilities

  1. Review medical documents and apply clinical criteria to establish the most appropriate level of care.
  2. Conduct retrospective utilization reviews and first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP.
  3. Prepare and present cases to Medical Directors for medical director oversight and necessity determination.
  4. Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.

The estimated salary for this position is around $83,000 - $110,000 per year, based on industry standards and location.



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