Blue Shield of California

Job Description

Your Role

The Delegation Oversight team is responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS, DHCS, LA Care and DMHC requirements including delegation standards and requirements contained in the delegation agreement. The Delegation Operations Nurse Auditor- RN - Senior will report to the Manager of UMDO. In this role you will assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit ensuring that departmental and organizational goals are accomplished through oversight and facilitating Utilization Management compliance of the Plan Partners.

Responsibilities

Your Work

In this role, you will:

• Be responsible for overseeing policy and procedure review and completing full/complex desk or onsite pre-delegation, Annual or follow-up audits/assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements.
• Act as the auditor in charge on large and complex audits – providing direction and guidance to support auditors of provider claims, provider dispute mechanism, credentialing and other delegated non-clinical areas through to corrective action plan oversight with minimal supervision required.
• Perform special audits of providers as requested by regulators, contracting, and internal management with oversight by Lead Auditor.
• May manage projects requiring the responsibility of delegating work and reviewing resulting work product.
• May be responsible for providing guidance, coaching and training to other employees within job area
• Develop and implement Corrective Action Plan (CAP) for medical groups that are out of compliance with delegated responsibilities, with timely follow up actions of CAP. Interpret statistics and plan for actions taken to improve utilization management
• Work with management to design and implement tools and materials that are compliant with regulatory, legislative and Blue Shield mandated requirements
• Design work plans and workflows to facilitate the audit, quality and cost of healthcare initiatives
• Responsible to assist in preparation of documents for NCQA, CMS, DHCS, LA Care and DMHC requirements, and/or other regulatory audits as needed
• Participate in industry collaborative teams

Qualifications

Your Knowledge and Experience

• Current CA RN license required
• Bachelors of Science in Nursing or advanced degree preferred
• Requires 5 years of prior relevant experience
• Requires 2 years of oncology experience
• Experience in auditing of claims, credentialing and/or re-credentialing preferred.
• Requires strong analytical and problem-solving skills
• Strong working knowledge of regulatory standards and regulations preferred
• Ability to solve complex issues and identify solutions preferred
• Desired knowledge of accreditation entities and their requirements
• Ability to work independently
• Excellent verbal and written communication skill and interpersonal skills
• Computer ease & literacy with Word, Excel, Power Point Skills preferred

ABOUT US

About Blue Shield of California and the Ascendiun Family of Companies

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Ascendiun, we believe in a brighter future for healthcare. As the parent to a family of four innovative healthcare companies, we’re reimagining what’s possible. Ascendiun is guided by the goal of transforming a dysfunctional American health care system into one worthy of our family and friends and sustainably affordable for everyone.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

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 listen and communicate effectively, and showing empathy by understanding others’ perspectives.
• 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:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. 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.

Pay Range for California $89100.00 to $133650.00 Pay Range for Bay Area $100440.00 to $150660.00 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 experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.