Clinical Nurse Auditor - RN, Consultant

Clinical Nurse Auditor - RN, Consultant

Your Role

The Clinical Access Programs 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

At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in , Join us!

Your Knowledge and Experience

• Requires an advanced degree, bachelors preferred or equivalent experience
• Requires a current CA RN License
• Requires at least 7 years of prior relevant experience
• Prior Quality Improvement experience, preferably in a managed care plan or IPA setting
• CCM, IQCI, CPLP preferred
• Health Plan and/or regulatory knowledge highly desired
• DHCS Certified Site Reviewer or eligible to be certified within 6 month of employment
• Expertise in Microsoft Office (Word, Excel, Outlook)
• Broad knowledge of Project Management
• Current drivers license and care insurance required

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.