Clinical Quality Auditor, Consultant; RN

Position: Clinical Quality Auditor, Consultant (RN) Location: California Clinical Quality Auditor, Consultant (RN) Join Blue Shield of California and apply for the Clinical Quality Auditor, Consultant (RN) role. In this position you will be part of the Quality Review team, completing audits of front‑line staff to ensure alignment with department processes and regulatory compliance. You will also provide coaching and work closely with business leaders to drive optimal results. The Clinical Quality Auditor, Consultant reports to the Quality Review Senior Manager and is responsible for developing performance metrics, evaluating performance, and coaching staff to achieve success in Population Health Management and Utilization Management.

Responsibilities

• Perform audits for Population Health Management (PHM) and Care Coordination, meeting 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 work redesign, process changes and software implementation.
• Act as a resource for the training and auditing team.

Qualifications

• Bachelor’s of Science in Nursing (BSN) required; advanced nursing degree preferred.
• Current California RN license required.
• At least 7 years of experience in managed care or a similar complex healthcare environment, with a minimum of 1 year experience in Case Management.
• Auditing experience preferred.
• Population Health Management and Utilization Management experience preferred.
• Strong organizational and/or project management skills to coordinate departmental projects and perform multiple projects or tasks simultaneously.
• Subject‑matter expert capable of effectively auditing and training all lines of business (Commercial, Federal Employee Program, Medicare, and Medi‑Cal).

About The Team As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that oversees Blue Shield of California and its subsidiaries, including 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. Blue Shield of California’s mission is to create a healthcare system worthy of our family and friends and sustainably affordable, transforming health care by lowering costs, improving quality, and enhancing member and physician experiences. Our Values

• Honest. We hold ourselves to the highest ethical and integrity standards and build trust by doing what we say we will do.
• Human. We listen and communicate effectively, showing empathy by understanding others’ perspectives.
• Courageous. We stand up for what we believe in and commit to the hard work necessary to achieve ambitious goals.

Physical Requirements Office Environment – This role involves part‑to‑full‑time work in our physical offices and may include remote work. Activity level: Sedentary; work is performed most of the day at a desk. 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 regard 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. #J-18808-Ljbffr Apply tot his job Apply To this Job