Delegation Operations Auditor, Senior

Blue Shield of California•Long Beach, CA

2d•Hybrid

About The Position

The Healthcare Quality Delegation Oversight team conducts routine and moderately complex audits of delegated entities to ensure delegate performance and compliance meets standards and focuses on quality and affordability of member care. The Delegation Operations Auditor, Senior role is a critical role within Blue Shield of California’s credentialing department. This role is responsible for assessing and ensuring the compliance of delegated entities with credentialing standards and regulatory requirements. Reporting to the Senior Manager of Delegation Operations, this role will conduct thorough audits and evaluations of the credentialing processes and data, ensuring that all providers within the delegated network meet established qualifications and standards. The Delegation Operations Auditor, Senior supports the improvement of credentialing practices and promotes high-quality care and patient safety within the network. 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 5 years of prior relevant experience in auditing of claims, credentialing and/or re-credentialing
Strong critical thinking, analytical, and problem-solving skills
Strong attention to detail skills and the ability to identify discrepancies and compliance issues
Strong understanding of credentialing standards, including those set by the National Committee for Quality Assurance (NCQA) and The Joint Commission
Strong interpersonal and communication skills, with the ability to work effectively with diverse teams and stakeholders
Ability to manage multiple priorities and deadlines in a dynamic environment, demonstrating strong organizational skills

Nice To Haves

Proficiency in credentialing and primary source verification software is preferred
Experience working in a health plan, hospital, or healthcare organization is preferred
Experience with accreditation processes and quality improvement initiatives related to credentialing is preferred
Familiarity with healthcare regulations and compliance requirements is preferred
Certification in healthcare credentialing (e.g., CPCS, CPMSM) is preferred

Responsibilities

Review and audit the credentialing processes of delegated providers to ensure compliance with internal policies, regulatory requirements, and industry standards
Analyze credentialing documentation, including licenses, certifications, education, training, and professional experience, to verify the qualifications of healthcare providers
Monitor adherence to precision and accuracy in the completion of credentialing applications and ongoing monitoring activities
Collaborate with internal compliance and quality assurance teams to identify areas for improvement and ensure consistency in credentialing practices across delegated entities
Develop and maintain audit checklists, protocols, and procedures to ensure effective oversight of credentialing practices
Prepare detailed reports summarizing audit findings, compliance issues, and recommendations for corrective actions, and present these findings to management and relevant stakeholders
Conduct educational sessions and provide support to delegated providers regarding credentialing requirements, best practices, and areas for improvement
Participate in regular meetings with team members and stakeholders to discuss audit results, emerging issues, and solutions to enhance credentialing processes
Assist in the development and implementation of policies and strategies to improve credentialing workflows and ensure timely credentialing of providers
Stay current with state and federal regulations, industry guidelines, and best practices in healthcare credentialing to ensure compliance and enhance auditing practices