Job Description

Your Role

The Delegation Operations (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. The Delegation Operations Auditor, Consultant will report to the Sr. Manager, Delegation Operations. In this role you will review new regulations and oversee implementation by contracted medical groups, IPAs, and specialty and RKK Plans. Additionally, this role involves oversight of internal controls - such as ownership, organizational structure, and other complex issues related to DMHC, DHCS, CMS, and LA Care requirements which influence the performance of the business unit or related functional areas in achieving Blue Shield of California's objectives.

Responsibilities

Your Work
In this role, you will:

• Be responsible for overseeing policy and procedure review and completing full/complex desk or pre-delegation, annual or follow-up onsite audits/assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements
• Act as the auditor in charge on large and complex audits of providers claims, provider dispute mechanism, credentialing, 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, credentialing management, financial solvency, and system controls
• Provide highly complex analysis and define efficiency in relation to compliance programs and internal controls
• Collaborate on regulatory audits, and findings responses
• Provide or coordinate technical assistance to delegates as needed to ensure they can comply with all requirements
• Assist Compliance Operations Advisor on regulatory enforcement audits
• Assist in the development of delegation policies and procedures and associated staff training
• Assist in the development of audit tools, correspondence templates, etc. to external entities

Qualifications

Your Knowledge and Experience

• Requires a Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• Requires 7 years of prior relevant experience in auditing delegated entities for DHCS requirements specific to provider training and education as it relates to diversity, equity, and inclusion with an emphasis on health equity
• Requires strong experience in auditing of internal controls, knowledge of all areas of health care delegated functions to assure a delegated provider has a strong understanding of CMS, DHCS, DMHC, etc. requirements and is meeting all contractual and regulatory requirements
• Requires experience with delegated provider group relations
• Strong critical thinking, analytical, and problem-solving skills
• Strong working knowledge of regulatory standards and regulations

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.