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.
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!