Clinical Nurse Auditor - RN, Consultant

Company: Blue Shield
Location: Long Beach
Posted on: November 6, 2024

Job Description:

Your Role
The Clinical Access Program's Facility Site Review team ensures that all MediCal members have access to safe, high-quality providers. The Clinical Nurse Auditor, Consultant will report to the Clinical Training and Auditing Manager. In this role you will survey physical site locations to ensure there is sufficient capacity to provide appropriate health care services, carry out process that support continuity and coordination of care, maintain patient safety standards and practices, and operate in compliance with all applicable local, state, and federal laws and regulations.
Your Work
In this role, you will:

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• Conduct clinical reviews of provider locations, including physicians, ancillary facilities, hospitals and other provider types, using established criteria and guidelines to evaluate the facility and medical records
  
• Collect data and issues Corrective Action Plans (CAP) as necessary, and track and follow up on CAPs and other information to be submitted to the Plan, to ensure evidence of corrective actions are in place
  
• Act as a liaison and provides support and resources to providers to assist in completing required corrective actions
  
• Report any instances of noncompliance, such as access issues or quality concerns, to the appropriate department along with recommended corrective actions
  
• Ensure all review documentation is completed, organized and entered into the program data system per established timelines
  
• Assist in preparation and conducting of required clinical auditing training, staff meetings, and/or offsite meetings as needed
  
• Participate in regulatory audits, workgroups/special projects for the department as assigned
  
• Train internal staff as needed
  
• Other duties as assigned
  
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Keywords: Blue Shield, Laguna Niguel , Clinical Nurse Auditor - RN, Consultant, Accounting, Auditing , Long Beach, California