Clinical Nurse Auditor - RN, Senior; MediCal

Your Role

The Population Health Management (PHM) team promotes a vision and strategy to drive differentiation in member experience and engagement, improvement in the overall health of Blue Shield of California members, and affordability and efficiency in the healthcare system. The Clinical Nurse Auditor, Senior will report to the Senior Manager of Care Management, PHM. In this role you will ensure compliance with NCQA and DHCS PHM requirements.

The Clinical Nurse Auditor, Senior will be responsible for understanding workflows, operational procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medi-Cal lines of businesses (LOBs). This position provides frontline support for nurses and care managers and works in collaboration with PHM leadership. The Clinical Nurse Auditor, Senior works closely with PHM Leaders and Delegated Entities to facilitate educational and training with case management assessments, documentations, etc.

in compliance with NCQA and DHCS PHM requirements

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

• Bachelor's of Science in Nursing or advanced degree preferred
• MSN or Master's degree in health related field preferred
• Requires at least 5 years of prior relevant experience
• CCM certification is preferred
• Requires current, active, and unrestricted California RN or NP licensure
• 3-5 years NCQA, DHCS, DHMC Care Management experience in a health plan or other managed care setting preferred
• 1 year as nursing lead or supervisor experience at a health plan or managed care plan preferred
• Excellent verbal and written communication style to drive positive outcomes
• Strong data analytic skills
• Resourceful and collaborative: a team collaborator with strong listening skills and the ability to offer creative solutions to drive consensus