Delegation Operations Auditor, Senior

JOB DESCRIPTION
Your Role

The Delegation Oversight (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. Reporting to the Manager, Delegation Oversight, the Delegation Operations Auditor, Senior is responsible for ensuring that delegates are compliant with all federal, state, and NCQA regulatory requirements with direct impact on the success of delegate compliance and organization oversight goals and objectives.

Your work

In this role, you will:

• Be responsible for overseeing policy and procedure review and completing full/complex pre-delegation, annual or follow-up onsite audits/assessments of delegated entities (including vendors) in support of the regulatory requirements
• Act as the auditor in charge on large and complex audits of provider claims, provider dispute mechanism, 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
• Develop format and document periodic status reports from Delegated Entities
• Provide or coordinate technical assistance to delegates as needed to ensure they can comply with all requirements

QUALIFICATIONS
Your Knowledge and Experience

• Requires a bachelor’s degree or equivalent experience
• Requires 5 years of prior relevant experience in auditing claims
• Strong analytical and problem-solving skills
• Advanced knowledge of delegate operations auditing
• Strong working knowledge of regulatory standards and regulations
• Strong verbal and written communication skills
• Strong knowledge of Microsoft Office products
• Strong organizational and attention to detail skills

Pay Range:

The pay range for this role is: $77,990.00 to $116,930.00 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.

ABOUT THE TEAM
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office

• Hybrid – In a business unit approved office a few times per year to 3 days per week, on average

• Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.