Delegation Operations Auditor, Consultant

Blue Shield of CA; Redding (CA); Hybrid; USD 95,000 - 130,000; Full time

Job summary

Blue Shield of California is seeking a Delegation Operations Auditor, Consultant to oversee audits of contracted entities and ensure compliance with CMS, DHCS, DMHC, and LA Care requirements.

You will review new regulations, coordinate with internal departments, and monitor internal controls across delegated provider groups, IPAs, and specialty plans, with emphasis on health equity. This hybrid role requires in-office collaboration two days weekly.

Qualifications

• Requires a Bachelor's degree or High School Diploma/GED with 4 years of additional relevant experience
• Requires 7 years of auditing delegated entities for DHCS requirements with focus on health equity
• Strong knowledge of CMS, DHCS, DMHC and other regulatory standards
• Experience with delegated provider group relations
• Strong critical thinking, analytical, and problem-solving skills
• Hybrid workplace model with in-office 2 days per week

Responsibilities

• Review new regulations and oversee implementation by contracted medical groups, IPAs, and specialty and RKK Plans
• Oversee internal controls related to ownership, organizational structure, and other complex issues per DMHC, DHCS, CMS, and LA Care requirements
• Coordinate with internal departments to monitor and audit delegated entities
• Ensure compliance with contractual and regulatory requirements
• Lead oversight activities with a focus on health equity and diversity, equity, and inclusion

Skills

Auditing delegated entities

Regulatory standards knowledge

Internal controls auditing

CMS/DHCS/DMHC knowledge

Provider group relations

Critical thinking

Analytical skills

Problem-solving

Health equity awareness

Education

Bachelor's degree or High School Diploma/GED with 4 years 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.

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.