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Blue Shield of California · 1 month ago

Clinical Quality Auditor, Consultant (RN)

Long Beach, CA, United States

Full-time

Hybrid

Mid, Senior Level

$123K/yr - $185K/yr

7+ years exp

Blue Shield of California is a nonprofit organization focused on transforming healthcare to be more affordable and effective. They are seeking a Clinical Quality Auditor, Consultant to perform audits, communicate findings, and provide coaching to ensure compliance and improve staff competencies in Population Health Management and Utilization Management.

Financial ServicesHealth InsuranceNon Profit

No H1B

Responsibilities

Perform audits for Population Health Management (PHM) and Care Coordination adhering to monthly productivity and quality metrics

Review audit data to identify care gaps, compliance risks, and trends

Communicate findings to leadership and provide recommendations to mitigate risks

Design, implement, evaluate and improve audit criteria and coaching strategies to meet the needs of PHM clinical staff

Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work

Conduct effective presentations relating to PHM processes and/or regulatory compliance for clinical staff

May independently represent the Quality Review department in PHM and work re-design, process changes and software implementation

Act as a resource for the training and auditing team

Qualification

California RN licensePopulation Health ManagementUtilization ManagementBachelor’s of Science in NursingAuditing experienceManaged care experienceTraining capabilitiesProject management skillsOrganizational skills

Required

Requires a Bachelor's of Science in Nursing or advanced degree preferred

Current California RN license required

At least 7 years of experience in managed care or similar complex healthcare environment with a minimum of 1 year experience in Case Management required

Strong organizational and/or project management skills to coordinate departmental projects and to perform multiple projects or tasks simultaneously

Subject matter expert with capability to effectively audit and train all lines of business (Commercial, Federal Employee Program, Medicare, and Medi-Cal)