Delegation Operations Auditor, Senior bei Blue Shield of California Group

Your Work

In this role, you will:

• 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

Your Knowledge and Experience

• Requires a Bachelor’s degree or equivalent years of experience
• Requires equivalent experience and 5 years of prior relevant experience in auditing of claims, credentialing and/or re-credentialing
• Experience working in a health plan, hospital, or healthcare organization is preferred
• Proficiency in credentialing and primary source verification software is preferred
• Experience with accreditation processes and quality improvement initiatives related to credentialing is preferred
• Familiarity with healthcare regulations and compliance requirements is preferred
• Certification in healthcare credentialing (e.g., CPCS, CPMSM) is preferred
• Strong understanding of credentialing standards, including those set by the National Committee for Quality Assurance (NCQA) and The Joint Commission
• Excellent analytical skills with a keen attention to detail and the ability to identify discrepancies and compliance issues
• 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

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun 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 Ascendiun 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 health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing 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 various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is 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. Here at Blue Shield, we strive to make a positive change across our industry and communities – 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 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. 

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o   Member-facing and approved out-of-state roles remain remote.

o   Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o   For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

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.

Please click here for further physical requirement detail. 

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.