Delegation Operations Auditor, Consultant

Socket.dev; Long Beach (CA); Hybrid; USD 120,000 - 180,000; Full time

Job summary

Blue Shield of California is seeking a Delegation Operations Auditor, Consultant to oversee audits of contracted delegated entities and ensure compliance with DMHC, DHCS, CMS requirements. You will review regulations and coordinate with internal teams to execute audits of provider claims, credentialing, and corrective actions.

This hybrid role supports collaboration across departments, with in-office days two per week in California.

Qualifications

• Bachelor’s degree or higher OR HS Diploma with 4 years additional relevant experience.
• 7 years of auditing delegated entities for DHCS/CMS requirements.
• Strong knowledge of CMS, DHCS, DMHC standards and related contracts.

Responsibilities

• Oversee policy and procedure reviews and conduct complex audits of delegated entities.
• Act as auditor in charge on audits of providers' claims, disputes, credentialing, and corrective action plans.
• Perform special audits of providers as requested by regulators and management.
• Research and monitor delegated entities' compliance with reporting requirements.
• Educate delegates on claims payment, credentialing, solvency, and controls.
• Provide complex analysis to improve compliance programs and internal controls.
• Collaborate on regulatory audits and findings responses.
• Assist in development of delegation policies, training, and audit tools.

Skills

Auditing delegated entities

Internal controls

Regulatory compliance

CMS/DHCS/DMHC knowledge

Data analysis

Communication

Education

Bachelor’s degree or HS Diploma + 4 years relevant experience

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.

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.

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.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. 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 achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield isa U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. 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 listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

OurWorkplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Ourworkplace modelis designed around intentional in-person interaction, collaboration, connection,creativityand flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right torequiremore presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.

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.