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Clinical Compliance Nurse, Consultant

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: May 17, 2023

Job Description:


Your Role

The Clinical Compliance Consultant, Medical Care Solutions is responsible for developing and maintaining the team's audit playbook for all lines of business for all regulatory and mock audits. Clinical Compliance Consultant is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The successful candidate will work with internal and external stakeholders understanding regulatory requirements, file preparation, letter and system accuracy, quality reporting, processes, and metrics. This role will own the regulatory and accreditation audit work plan for function by understanding workflows, operational procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). This position provides frontline support for nurses and coordinators and works in collaboration with leadership. The Clinical Compliance Consultant works closely with subject matter experts for each line of business (LOB) to facilitate educational and change management processes as needed.

Your Work

In this role, you will:

Develop new perspectives and innovative approaches on existing problems; require detailed information gathering, analysis and investigation to understand the problem. Problems are difficult and moderately complex, typically impact multiple departments or specialties, and are usually solved through drawing from prior experience and analysis of issues.

Track and follow up on Corrective Action Plans (CAPs) and other information to be submitted to the Plan, to ensure evidence of corrective actions are in place.

Provide expert consultation and practice oversight of regulation adherence.

Design, develop and maintain an audit playbook and audit knowledge base repository; lead preparation and support for multiple regulatory audits annually, including audit universe and file prep.

Facilitate file and audit practice sessions with internal stakeholders.

Work with internal stakeholders to assure changing contractual and All Plan Letter (APL) requirements are incorporated into policies and procedures, as well as UM processes.

Department owner for UM Policy and Procedure updates to maintain alignment with APL and contractual requirements.

Generally, responsible for managing major/complex projects involving delegation of work and review of work products; participates in workgroups/special projects for department as assigned.

Responsible for making moderate to significant improvements of processes, systems and products to enhance performance of job area.

Works to influence parties within and outside of the job function at an operational level regarding policies, procedures and practices.


Your Knowledge and Experience

Requires a bachelors degree or equivalent experience

Requires at least 7 years of prior relevant experience

Current California RN license required

Experience with, or strong working knowledge of, regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) and managed care for various lines of business (HMO, PPO, Medicare, Medi-Cal, Cal Medi-Connect)

Strong project management skills with multi-initiative leadership experience required

Strong verbal/written communication and organizational skills

Proficient in use of PC-based software programs including Microsoft Word, Excel, PowerPoint, and Outlook with strong typing skills required

Ability to work independently in a fast-paced and fluid work environment

Consistent demonstration of knowledge, skills, abilities, and behaviors needed to provide superior and culturally sensitive service to team members

Pay Range:

The pay range for this role is: $ 109120.00 to $ 163680.00 for California.


Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.


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!


Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - 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 be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.

Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

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.

COVID-19 Vaccination Policy:

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain an accommodation within 30 days, your offer will be rescinded.

Keywords: Blue Shield of California, Rancho Cordova , Clinical Compliance Nurse, Consultant, Healthcare , Rancho Cordova, California

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