Delegation Operations Nurse Auditor - RN, Senior

Blue Shield of California•Long Beach, CA

6d•Hybrid

About The Position

Your Role The Delegation Oversight team is responsible for driving continuous quality improvement across delegated functions and ensuring compliance with applicable regulatory, contractual, and accreditation requirements. The team oversees delegated activities in accordance with NCQA, CMS, DHCS, L.A. Care, and DMHC standards, as well as delegation requirements outlined in executed delegation agreements. 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. Responsibilities Your Work In this role, you will: Lead and perform utilization management full-scope, complex desk and onsite audits (pre‑delegation, annual, follow‑up, and focused audits) of delegated entities and vendors, ensuring compliance with regulatory, contractual, and NCQA requirements. Serve as auditor-in-charge for large and complex audits, providing direction and guidance to auditors reviewing provider claims, provider dispute mechanisms, credentialing, and other delegated non‑clinical functions, through audit completion and corrective action plan (CAP) oversight, with minimal supervision. Conduct special and ad hoc audits of providers and delegated entities at the request of regulators, contracting, or internal leadership, with oversight from the Lead Auditor as appropriate. Lead or manage special projects, including delegating work assignments, reviewing audit deliverables, and ensuring accuracy, quality, and timeliness of work products. Provide guidance, coaching, and training to other auditors and staff within the job function to support skill development, audit consistency, and regulatory readiness. Develop, implement, and monitor Corrective Action Plans (CAPs) for medical groups and delegated entities found to be out of compliance, ensuring timely follow‑up and sustained remediation. Analyze audit findings, trends, and performance data to interpret utilization management outcomes and recommend improvement actions to enhance compliance, quality, and efficiency. Partner with management to design and implement audit tools, workflows, and training materials that meet regulatory, legislative, NCQA, and Blue Shield requirements. Design and refine audit work plans and workflows that support quality improvement initiatives while balancing audit effectiveness, efficiency, and healthcare cost considerations. Assist in the preparation of documentation and responses for NCQA, CMS, DHCS, L.A. Care, DMHC, and other regulatory or accreditation audits as needed. Participate in industry workgroups, collaborative teams, and regulatory forums to stay current on evolving delegation oversight, utilization management, and compliance requirements.

Requirements

Bachelor's of Science in Nursing or advanced degree preferred
Current, unrestricted California Registered Nurse (RN) license required
5 years of relevant professional experience required
Strong analytical, investigative, and problem solving skills
Ability to independently assess complex compliance issues and identify effective solutions
Excellent verbal, written, and interpersonal communication skills
Ability to work independently with minimal supervision in a fast paced, regulatory environment
Proficiency with Microsoft Word, Excel, and PowerPoint
Experience in auditing utilization management strongly preferred
Strong working knowledge of regulatory and accreditation standards, including NCQA, CMS, DHCS, L.A. Care, and DMHC preferred
Knowledge of delegation oversight requirements and health plan operations preferred
Experience supporting or participating in regulatory or accreditation audits preferred

Responsibilities

Lead and perform utilization management full-scope, complex desk and onsite audits (pre‑delegation, annual, follow‑up, and focused audits) of delegated entities and vendors, ensuring compliance with regulatory, contractual, and NCQA requirements.
Serve as auditor-in-charge for large and complex audits, providing direction and guidance to auditors reviewing provider claims, provider dispute mechanisms, credentialing, and other delegated non‑clinical functions, through audit completion and corrective action plan (CAP) oversight, with minimal supervision.
Conduct special and ad hoc audits of providers and delegated entities at the request of regulators, contracting, or internal leadership, with oversight from the Lead Auditor as appropriate.
Lead or manage special projects, including delegating work assignments, reviewing audit deliverables, and ensuring accuracy, quality, and timeliness of work products.
Provide guidance, coaching, and training to other auditors and staff within the job function to support skill development, audit consistency, and regulatory readiness.
Develop, implement, and monitor Corrective Action Plans (CAPs) for medical groups and delegated entities found to be out of compliance, ensuring timely follow‑up and sustained remediation.
Analyze audit findings, trends, and performance data to interpret utilization management outcomes and recommend improvement actions to enhance compliance, quality, and efficiency.
Partner with management to design and implement audit tools, workflows, and training materials that meet regulatory, legislative, NCQA, and Blue Shield requirements.
Design and refine audit work plans and workflows that support quality improvement initiatives while balancing audit effectiveness, efficiency, and healthcare cost considerations.
Assist in the preparation of documentation and responses for NCQA, CMS, DHCS, L.A. Care, DMHC, and other regulatory or accreditation audits as needed.
Participate in industry workgroups, collaborative teams, and regulatory forums to stay current on evolving delegation oversight, utilization management, and compliance requirements.