Your Role

The Delegation Operations (DO) team, under the purview of the Delegation Oversight Committee (DOC) which is a sub-committee of the Quality Oversight Committee (QOC), is responsible for oversight of contracted delegated entities. This includes auditing, corrective actions follow-up and monitoring activities. The DO team will coordinate with other internal departments on oversight activities.

The Delegation Operations Auditor, Consultant will report to the Manager, Delegation Operations. This role is responsible for compliance program effectiveness review, DHCS Newly Contracted Provider Training audits as well as oversight of internal controls - such as ownership, organizational structure, and other complex issues related to DMHC, DHCS, CMS and LA Care requirements. The Delegation Operations Auditor, Consultant influences the performance of the business unit or related functional areas in achieving Blue Shield of California's objectives.

Your Work

In this role, you will:

• Be responsible for overseeing policy and procedure review and completing full/complex desk or pre-delegation, annual or follow-up onsite 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 of providers claims, provider dispute mechanism, credentialing, and other delegated non-clinical areas through to corrective action plan oversight
• Perform special audits of providers as requested by regulators, contracting, and internal management
• Research, investigate and oversee delegated entity's compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports
• Educate the delegated entities and vendors on area of expertise including but not limited to claims payment management, credentialing management, financial solvency, and system controls
• Provide highly complex analyses and defines efficiency in relation to compliance programs and internal controls
• Collaborate on regulatory audits, and findings responses
• Provide or coordinate technical assistance to delegates as needed to ensure they can comply with all requirements
• Assist Compliance Operations Advisor on regulatory enforcement audits
• Assist in the development of delegation policies and procedures and associated staff training. Assist in the development of audit tools, correspondence templates, etc. to external entities

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires at least 7 years of experience within a managed healthcare organization in auditing of compliance program for effectiveness meeting requirements of CMS, DMHC, and DHCS
• Requires prior experience in auditing delegated entities for DHCS requirements specific to provider training, provider education as it relates to diversity, equity, and inclusion with an emphasis on health equity
• Requires experience with Delegated Provider Group Relations
• Requires excellent analytical and problem-solving skills
• Requires strong working knowledge of regulatory standards and regulations

Pay Range:

The pay range for this role is: $ 96,470.00 to $ 144,760.00 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.