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Clinical Nurse Auditor Consultant

2 months ago

Long Beach CA USA, United States Blue Shield of California Full time
About the Role

We are seeking a highly skilled Clinical Nurse Auditor Consultant to join our team at Blue Shield of California. As a key member of our Clinical Access Program's Facility Site Review team, you will play a critical role in ensuring that all MediCal members have access to safe, high-quality providers.

Key Responsibilities
  • Conduct clinical reviews of provider locations, including physicians, ancillary facilities, hospitals, and other provider types, using established criteria and guidelines to evaluate the facility and medical records.
  • Collect data and issue Corrective Action Plans (CAPs) as necessary, and track and follow up on CAPs and other information to be submitted to the Plan, to ensure evidence of corrective actions are in place.
  • Act as a liaison and provide support and resources to providers to assist in completing required corrective actions.
  • Report any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actions.
  • Ensure all review documentation is completed, organized, and entered into the program data system per established timelines.
  • Assist in preparation and conducting of required clinical auditing training, staff meetings, and/or offsite meetings as needed.
  • Participate in regulatory audits, workgroups/special projects for the department as assigned.
  • Train internal staff as needed.
Requirements
  • Bachelor's or Advanced Degree preferred.
  • Requires a current CA RN License and 7+ years of prior relevant experience and/or training, or equivalent combination.
  • CCM, IQCI, CPLP preferred.
  • Excellent analytical and problem-solving skills.
  • Requires deep knowledge of job area typically obtained through advanced education combined with experience.
  • Typically, viewed as a specialist within discipline. May have broad knowledge of project management.
  • Health Plan and/or regulatory knowledge highly desired.
  • DHCS Certified Site Reviewer or eligible to be certified within 6 months of employment.