Delegation Operations Auditor, Senior

About the Role

The Healthcare Quality Delegation Oversight team conducts routine and moderately complex audits of delegated entities to ensure delegate performance and compliance meets standards, focusing on quality and affordability of member care. The Delegation Operations Auditor, Senior is a critical role within Blue Shield of California’s credentialing department, responsible for assessing and ensuring the compliance of delegated entities with credentialing standards and regulatory requirements.

Reporting to the Senior Manager of Delegation Operations, this role will conduct thorough audits and evaluations of the credentialing processes and data, ensuring all providers within the delegated network meet established qualifications and standards. The role supports the improvement of credentialing practices and promotes high-quality care and patient safety within the network.

Our leadership model focuses on developing great leaders at all levels and creating opportunities for personal, professional, and financial growth. We seek leaders energized by creative and critical thinking, building high-performing teams, achieving results ethically, and fostering continuous learning.

Responsibilities

• Review and audit the credentialing processes of delegated providers to ensure compliance with internal policies, regulatory requirements, and industry standards.
• Analyze credentialing documentation, including licenses, certifications, education, training, and professional experience, to verify the qualifications of healthcare providers.
• Monitor adherence to precision and accuracy in the completion of credentialing applications and ongoing monitoring activities.
• Collaborate with internal compliance and quality assurance teams to identify areas for improvement and ensure consistency in credentialing practices across delegated entities.
• Develop and maintain audit checklists, protocols, and procedures to ensure effective oversight of credentialing practices.
• Prepare detailed reports summarizing audit findings, compliance issues, and recommendations for corrective actions, and present these findings to management and relevant stakeholders.
• Conduct educational sessions and provide support to delegated providers regarding credentialing requirements, best practices, and areas for improvement.
• Participate in regular meetings with team members and stakeholders to discuss audit results, emerging issues, and solutions to enhance credentialing processes.
• Assist in the development and implementation of policies and strategies to improve credentialing workflows and ensure timely credentialing of providers.
• Stay current with state and federal regulations, industry guidelines, and best practices in healthcare credentialing to ensure compliance and enhance auditing practices.

Requirements

• Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree.
• 5 years of prior relevant experience in auditing of claims, credentialing, and/or re-credentialing.
• Strong critical thinking, analytical, and problem-solving skills.
• Strong attention to detail and the ability to identify discrepancies and compliance issues.
• Strong understanding of credentialing standards, including those set by the National Committee for Quality Assurance (NCQA) and The Joint Commission.
• Strong interpersonal and communication skills, with the ability to work effectively with diverse teams and stakeholders.
• Ability to manage multiple priorities and deadlines in a dynamic environment, demonstrating strong organizational skills.

Preferred Qualifications

• Proficiency in credentialing and primary source verification software.
• Experience working in a health plan, hospital, or healthcare organization.
• Experience with accreditation processes and quality improvement initiatives related to credentialing.
• Familiarity with healthcare regulations and compliance requirements.
• Certification in healthcare credentialing (e.g., CPCS, CPMSM).

Schedule

This role follows a hybrid workplace model, requiring employees to work in-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.

Pay

Pay Range for California: $81,950.00 to $122,870.00

Pay Range for Bay Area: $92,380.00 to $138,508.00

Note: This range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Salaries are based on candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

About Us

As of January 2025, Blue Shield of California became a subsidiary of Ascendium. Ascendium is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, 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 Ascendium Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming healthcare to lower costs, improve quality, and enhance the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the communities we serve.

Blue Shield is recognized as a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company, and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company and one of the 50 most community-minded companies in the United States by Points of Light.

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 acknowledging and correcting where we fall short.
• Human: We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous: We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Physical Requirements

This role involves part- to full-time work in an office environment, with a sedentary activity level for most of the workday.