Delegation Oversight Clinical Nurse Auditor - LVN, Senior

Blue Shield of California•Long Beach, CA

11h•$90,860 - $153,636•Hybrid

About The Position

The Delegation Oversight Clinical Nurse Auditor - LVN, Senior independently conducts comprehensive delegation oversight audits to evaluate delegated entities’ compliance with California Department of Managed Health Care (DMHC) All Plan Letter (APL) 24-019 and Rule 1300.67.2.2. The position conducts regulatory compliance assessments of delegated medical groups, Independent Practice Associations (IPAs), Management Services Organizations (MSOs), and other contracted entities to verify the accuracy, completeness, and reliability of information provided to the health plan for regulatory oversight. As a senior-level auditor, this role independently manages complex audit assignments, evaluates regulatory risks, develops findings, monitors corrective actions, and provides technical guidance to delegated entities. It supports the organization’s regulatory readiness and accountability for delegated functions, and operates with limited supervision. The role reports to the Delegations Oversight Compliance Manager. The role is hybrid. For most teams, this means working in the office two days each week. Employees who live more than 50 miles from an office location work with their manager to determine in-office time based on business needs. The position is based in an office environment and involves sedentary activity for most of the workday, including office and work-from-home deskwork.

Requirements

High school diploma or GED and completion of a state-approved Vocational Nursing (LVN) program.
Current unrestricted California LVN license.
Five years of prior relevant experience.
Strong critical-thinking, analytical, and problem-solving skills.
Ability to operate independently with limited supervision.

Nice To Haves

Familiarity with DMHC APL 24-019, Rule 1300.67.2.2, and Annual Network Reporting requirements.
Understanding of auditing practices for delegated medical groups, IPAs, or MSOs.

Responsibilities

Oversee delegated groups’ and vendors’ policies, procedures, utilization management, and related activities.
Monitor compliance with APL 25-019 out-of-network provider access requirements, including Letters of Agreement (LOAs), Memoranda of Understanding (MOUs), and concierge services; perform on-site and virtual audits.
Independently plan, coordinate, and conduct annual, focused, and for-cause audits of delegated entities’ compliance with applicable APL 24-019 requirements.
Assess delegated policies, procedures, workflows, and internal controls supporting Annual Network Reporting.
Substantiate compliance findings through document reviews, data validation, sampling, and interviews.
Identify regulatory deficiencies, operational gaps, and systemic compliance risks.
Document clear and accurate audit findings supported by evidence, linking deficiencies to applicable regulatory, contractual, or organizational requirements.
Review corrective action plans, assess root-cause analyses and proposed actions, and track implementation and completion deadlines.
Refer recurring findings, unresolved deficiencies, and material regulatory risks to management for escalation.
Maintain complete and accurate audit and corrective action records.
Produce audit reports detailing findings, supporting evidence, regulatory references, and required corrective actions.
Examine delegated groups’ reports to verify compliance with specific regulations.
Partner with Blue Shield staff on regulatory audits, corrective action plans, and regulatory agency enforcement actions.
Educate medical groups and IPAs about changes to regulatory requirements and/or accreditation standards.
Pursue operational targets that directly affect departmental results.
May assume full responsibility for projects or processes within the role’s scope.
Perform additional duties as assigned.