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Full Job Description
Your Role
The Clinical Access Program’s
Facility Site Review team ensures that all MediCal members have access
to safe, high-quality providers. The Clinical Nurse Auditor, Senior
will report to the Clinical Training and Auditing Manager. In this
role you will survey physical site locations to ensure there is
sufficient capacity to provide appropriate health care services, carry
out process that support continuity and coordination of care, maintain
patient safety standards and practices, and operate in compliance with
all applicable local, state, and federal laws and regulations.
Your Work
In this role, you will:
- Conduct clinical reviews of provider locations, including
physicians, ancillary facilities, hospitals and other provider types,
using established criteria and guidelines to evaluate the facility and
medical records. - Collect data and issues Corrective
Action Plans (CAP) as necessary, and track and follow up on CAPs and
other information to be submitted to the Plan, to ensure evidence of
corrective actions are in place. - Act as a liaison and
provides support and resources to providers to assist in completing
required corrective actions. - Report any instances of
noncompliance, such as access issues or quality concerns, to the
appropriate department along with recommended corrective actions. - Ensure all review documentation is completed, organized and
entered into the program data system per established timelines. - Assist in preparation and conducting of required clinical auditing
training, staff meetings, and/or offsite meetings as needed. - Participate in regulatory audits, workgroups/special projects for
the department as assigned - Train internal staff as needed.
- Other duties as assigned.
At Blue Shield of
California we are parents, leader, students, visionaries, heroes, and
providers. Everyday we come together striving to fulfill our mission,
to ensure all Californians have access to high-quality health care at
a sustainably affordable price. For more than 80 years, Blue Shield of
California has been dedicated to transforming health care by making it
more accessible, cost-effective, and customer-centric. We are a
not-for-profit, independent member of the Blue Cross Blue Shield
Association with 6,800 employees, more than $20 billion in annual
revenue and 4.3 million members. The company has contributed more than
$500 million to Blue Shield of California Foundation since 2002 to
have a positive impact on California communities. Blue Shield of
California is headquartered in Oakland, California with 18 additional
locations including Sacramento, Los Angeles, and San Diego. We’re
excited to share Blue Shield of California has received awards and
recognition for LGBT diversity, quality improvement, most influential
women in corporate America, Bay Area’s top companies in volunteering &
giving, and one of the world’s most ethical companies. Here at Blue
Shield of California, we’re striving to make a positive change across
our industry and the communities we live in , Join us!
Your
Knowledge and Experience
- Requires a bachelor’s
degree or equivalent experience - Requires a current CA RN
License - Requires at least 5 years of prior relevant
experience - Prior Quality Improvement experience, preferably
in a managed care plan or IPA setting - Health Plan and/or
regulatory knowledge highly desired - DHCS Certified Site
Reviewer or eligible to be certified within 6 month of employment - Expertise in Microsoft Office (Word, Excel, Outlook)
- Current driver’s license and care insurance required
Pay Range:
The pay range for
this role is $ 85360.00 to $ 128040.00 for California.
Note:
Please note that this range
represents the pay range for this and many other positions at Blue
Shield that fall into this pay grade. Blue Shield salaries are based
on a variety of factors, including the candidate’s experience,
location (California, Bay area, or outside California), and current
employee salaries for similar roles.
