Job Description

Your Role

The Healthcare Quality Delegation Oversight team conducts routine and moderately complex audits of delegated entities to ensure delegate performance and compliance meets standards and focuses on quality and affordability of member care. The Delegation Operations Auditor, Senior role is a critical role within Blue Shield of California's credentialing department. This role is responsible for assessing and ensuring the compliance of delegated entities with credentialing standards and regulatory requirements. Reporting to the Senior Manager of Delegation Operations, this role will conduct thorough audits and evaluations of the credentialing processes and data, ensuring that all providers within the delegated network meet established qualifications and standards. The Delegation Operations Auditor, Senior supports the improvement of credentialing practices and promotes high-quality care and patient safety within the network.

Responsibilities

Your Work
In this role, you will:

• Review and audit the credentialing processes of delegated providers to ensure compliance with internal policies, regulatory requirements, and industry standards
• Analyze credentialing documentation, including licenses, certifications, education, training, and professional experience, to verify the qualifications of healthcare providers
• Monitor adherence to precision and accuracy in the completion of credentialing applications and ongoing monitoring activities
• Collaborate with internal compliance and quality assurance teams to identify areas for improvement and ensure consistency in credentialing practices across delegated entities
• Develop and maintain audit checklists, protocols, and procedures to ensure effective oversight of credentialing practices
• Prepare detailed reports summarizing audit findings, compliance issues, and recommendations for corrective actions, and present these findings to management and relevant stakeholders
• Conduct educational sessions and provide support to delegated providers regarding credentialing requirements, best practices, and areas for improvement
• Participate in regular meetings with team members and stakeholders to discuss audit results, emerging issues, and solutions to enhance credentialing processes
• Assist in the development and implementation of policies and strategies to improve credentialing workflows and ensure timely credentialing of providers
• Stay current with state and federal regulations, industry guidelines, and best practices in healthcare credentialing to ensure compliance and enhance auditing practices

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 5 years of prior relevant experience in auditing of claims, credentialing and/or re-credentialing
• Strong critical thinking, analytical, and problem-solving skills
• Strong attention to detail skills and the ability to identify discrepancies and compliance issues
• Strong understanding of credentialing standards, including those set by the National Committee for Quality Assurance (NCQA) and The Joint Commission
• Strong interpersonal and communication skills, with the ability to work effectively with diverse teams and stakeholders
• Ability to manage multiple priorities and deadlines in a dynamic environment, demonstrating strong organizational skills
• Proficiency in credentialing and primary source verification software is preferred
• Experience working in a health plan, hospital, or healthcare organization is preferred
• Experience with accreditation processes and quality improvement initiatives related to credentialing is preferred
• Familiarity with healthcare regulations and compliance requirements is preferred
• Certification in healthcare credentialing (e.g., CPCS, CPMSM) is preferred

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.

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