Delegation Operations Auditor, Consultant

Blue Shield of California•Long Beach, CA

3d•Hybrid

About The Position

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 Sr. Manager, Delegation Operations. In this role you will review new regulations and oversee implementation by contracted medical groups, IPAs, and specialty and RKK Plans. Additionally, this role involves oversight of internal controls – such as ownership, organizational structure, and other complex issues related to DMHC, DHCS, CMS, and LA Care requirements which influence the performance of the business unit or related functional areas in achieving Blue Shield of California’s objectives. 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.

Requirements

Requires a Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
Requires 7 years of prior relevant experience in auditing delegated entities for DHCS requirements specific to provider training and education as it relates to diversity, equity, and inclusion with an emphasis on health equity
Requires strong experience in auditing of internal controls, knowledge of all areas of health care delegated functions to assure a delegated provider has a strong understanding of CMS, DHCS, DMHC, etc. requirements and is meeting all contractual and regulatory requirements
Requires experience with delegated provider group relations
Strong critical thinking, analytical, and problem-solving skills
Strong working knowledge of regulatory standards and regulations

Responsibilities

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 analysis and define 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