About this role
Your Role
The Population Health Management (PHM) team promotes a vision and strategy to drive differentiation in member experience and engagement, improvement in the overall health of Blue Shield of California members, and affordability and efficiency in the healthcare system. The Clinical Nurse Auditor, Senior will report to the Senior Manager of Care Management, PHM. In this role you will ensure compliance with NCQA and DHCS PHM requirements. The Clinical Nurse Auditor, Senior will be responsible for understanding workflows, operational procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medi-Cal lines of businesses (LOBs). This position provides frontline support for nurses and care managers and works in collaboration with PHM leadership. The Clinical Nurse Auditor, Senior works closely with PHM Leaders and Delegated Entities to facilitate educational and training with case management assessments, documentations, etc. in compliance with NCQA and DHCS PHM requirements
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work
In this role, you will:
- Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California strategic goals
- Consult with all levels including senior management, make recommendations, and influence decision-making
- Leverage cross-functional internal and external relationships to drive initiatives forward
- Plan and implement multiple and extremely complex projects/programs spanning across business areas
- Determine key business issues, develop effective action plans and implement to successful conclusion
- Conduct comprehensive audits of PHM’s and Delegated entities care management process, document reviews, and process evaluations.
- Identify and document any deviations, non-compliance issues, and areas for improvement.
- Prepare detailed audit reports and present findings to relevant stakeholders.
- Provide training and guidance to clinical staff on quality standards and regulatory requirements.
- Stay updated on industry trends, regulatory changes, and best practices in clinical quality assurance.
- Present Care Management and PHM data and outcomes to executive leadership related to Clinical Eligibility & Appropriateness
- Review and validate member clinical eligibility for Complex Case Management (CCM) and Assisted Living Waiver (ALW) participation, ensuring alignment with NCQA and DCHS criteria and medical necessarily prior and throughout the referral/enrollment process.
- Vendor Oversight and Progress Monitoring: Provide ongoing clinical oversight of CCM and HCBA vendor activities (referral submission, application completion, waitlist management), ensuring timely progression of members and preventing passive case holding or inappropriate billing).
- Quality Documentation & Escalation: Monitor documentation, status updates, plans to ensure clear outcomes and that they are escalating barriers/delays that
Your Knowledge and Experience
Bachelor's of Science in Nursing or advanced degree preferred
MSN or Master’s degree in health related field preferred
Requires at least 5 years of prior relevant experience
CCM certification is preferred
Requires current, active, and unrestricted California RN or NP licensure
3-5 years NCQA, DHCS, DHMC Care Management experience in a health plan or other managed care setting preferred
1 year as nursing lead or supervisor experience at a health plan or managed care plan preferred
Excellent verbal and written communication style to drive positive outcomes
Strong data analytic skills
Resourceful and collaborative: a team collaborator with strong listening skills and the ability to offer creative solutions to drive consensus