Delegation Operations Auditor, Consultant at Blue Shield of CA in El Dorado Hills, California

Job Description:

Job Summary

This position will perform the following types of reviews and audits that would address the requirementsand recent agreements between DMHC and the Plans. This would include system integrity audits,compliance program review, and for DHCS Newly Contracted Provider Training audits as well asoversight of internal controls - such as ownership, organizational structure, and other complex issuesrelated to DMHC, DHCS, CMS and LA Care requirements. These positions will work closely with financeon reviews of systems and operations based upon repeated financial solvency CAPs as reported by theDMHC or as determined by Blue Shield of California's review of the annual/quarterly financialstatements.

Responsibilities

• Responsible for performing regulatory/contractual delegation oversight control audits to ensure compliance with Federal and State regulatory agencies. Assures compliance to external specifications and standards. Conducts comprehensive regulatory reviews using a standard audit model.


• Provides highly complex analysis and defines efficiency in relation to compliance programs and internal controls.


• Coordinates the audit of compliance programs and internal controls with other internal and external audit teams.


• Provide administrative oversight of 3rd party relationships with performance/tracking systems.


• Participate in special projects as needed.


• Responsible for proactively improving upon existing processes and systems using significant conceptualizing, reasoning and interpretation.


• Works to influence others to accept audit results and accountability for audit results.


• Results may serve as precedent for future decisions.


• Problems and issues faced are numerous, and typically undefined where information is difficult to obtain.


• Conducts extensive investigation, critical thinking to understand root cause of problems. Problems span a wide range of difficult and unique issues across functions and/or businesses.


• Develops new perspectives and innovative approaches on existing or new problems.


• Applies agile methods.


• Communicates with parties within and outside of own job function.


• Has responsibilities for communicating with parties' external to the organization, which may include customers or vendors.


• Works to influence others to accept job function's view/practices, and agree to or accept new concepts, practices, and approaches.


• Requires ability to communicate with executive leadership regarding matters of significant importance to the organization.


• Generally, conducts briefings with senior leaders within the job function.


• Provide guidance and training externally to provider organizations.


• Responsible for managing large, complex project initiatives of strategic importance to the organization, involving large cross-functional teams.


• May direct the work of other individual contributors and/or act as a cross-functional team lead.


• Other duties as assigned.

Knowledge, Experience and Education

• May require a bachelor's degree or equivalent and minimal to moderate experience in managed care setting, healthcare industry or related field.


• Extensive experience in health care specific to compliance-operations, privacy, audit and legal investigative services.


• Requires deep job knowledge and application typically obtained through advanced education combined with experience.


• Minimum of 10 years of prior relevant experience within a managed healthcare organization with an emphasis on compliance.


• Certification from HCCA or equivalent experience or training.

Additional Information

• About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!










• 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.
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• EEO Footer: 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.











• Requisition ID: 210014E













• Posting Date: Feb 8, 2021











• Schedule: Full-time

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