Blue Shield of California · 1 month ago
Clinical Quality Auditor, Consultant (RN)
California, United States
Full-time
Hybrid
Senior Level
7+ years expBlue Shield of California is a nonprofit organization committed to transforming healthcare to be more affordable and effective. The Clinical Quality Auditor, Consultant will perform audits, evaluate performance, and provide coaching to ensure staff success in Population Health Management and Utilization Management.
Financial ServicesHealth InsuranceNon Profit
Responsibilities
Perform audits for Population Health Management (PHM) and Care Coordination adhering to monthly productivity and quality metrics
Review audit data to identify care gaps, compliance risks, and trends
Communicate findings to leadership and provide recommendations to mitigate risks
Design, implement, evaluate and improve audit criteria and coaching strategies to meet the needs of PHM clinical staff
Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work
Conduct effective presentations relating to PHM processes and/or regulatory compliance for clinical staff
May independently represent the Quality Review department in PHM and work re-design, process changes and software implementation
Act as a resource for the training and auditing team
Qualification
Required
Current California RN license required
At least 7 years of experience in managed care or similar complex healthcare environment with a minimum of 1 year experience in Case Management required
Strong organizational and/or project management skills to coordinate departmental projects and to perform multiple projects or tasks simultaneously
Subject matter expert with capability to effectively audit and train all lines of business (Commercial, Federal Employee Program, Medicare, and Medi-Cal)
Preferred
Auditing experience preferred
Population Health Management and Utilization Management experience preferred
Bachelor's of Science in Nursing or advanced degree preferred
Company
Blue Shield of California
Blue Shield of California is a health insurance service provider.
5001-10000 employees
H1B Sponsorship
Blue Shield of California has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2023 (1)
2022 (41)
2021 (20)
2020 (31)
Funding
Current Stage
Late StageLeadership Team
Gary Culp
Senior Vice President, Government Markets
Gregory Siebert
Senior Vice President Provider Partnerships & Network Management
Recent News
2026-01-13
Fierce Healthcare
2025-12-15
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