Clinical Nurse Auditor - RN, Consultant

Job Description

Your Role

The Clinical Access Program’s Facility Site Review team ensures that all MediCal members have access to safe, high-quality providers. The Clinical Nurse Auditor, Senior will report to the Clinical Training and Auditing Manager. In this role you will survey physical site locations to ensure there is sufficient capacity to provide appropriate health care services, carry out process that support continuity and coordination of care, maintain patient safety standards and practices, and operate in compliance with all applicable local, state, and federal laws and regulations.

Your Work

In this role, you will:

• 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 issues Corrective Action Plans (CAP) 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 provides 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
• Other duties as assigned
  
  

Qualifications

Your Knowledge and Experience

• Bachelors 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.
• Typically requires a college degree or equivalent experience and minimum 7 years of prior relevant experience.
• Health Plan and/or regulatory knowledge highly desired
• DHCS Certified Site Reviewer or eligible to be certified within 6 month of employment
  
  

Pay Range:

The pay range for this role is $109120.00 to $163680.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

About The Team

Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
  
  

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office

• Hybrid – In a business unit approved office a few times per year to 3 days per week, on average
• Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
  
  

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.