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

Your Knowledge and Experience

• Bachelors or Advanced degree preferred
• Requires a current CA RN License and 7+ years of prior relevant experience and/or training, or equivalent combination
• CCM, IQCI, CPLP preferred
• Excellent analytical and problem-solving skills
• Requires deep knowledge of job area typically obtained through advanced education combined with experience
• Typically, viewed as a specialist within discipline. May have broad knowledge of project management.
• Typically requires a college degree or equivalent experience and minimum 7 years of prior relevant experience.
• Health Plan and/or regulatory knowledge highly desired
• DHCS Certified Site Reviewer or eligible to be certified within 6 month of employment

Pay Range:

The pay range for this role is $109120.00 to $163680.00 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.