Delegation Operations Nurse Auditor - LVN, Experienced at Blue Shield of California Group

Your Work

In this role, you will:

• Be responsible for overseeing policy and procedure review and completing limited and less complex full desk or onsite Pre-delegation, Annual or follow-up audits assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements.
• Act as the auditor in charge on small and less complex audits, with supervision, of Sr. management and other delegated non-clinical areas through to corrective action plan oversight.
• Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
• Educate the delegated entities and vendors on area of expertise including but not limited to claims payment management, credentialing management, financial solvency, and system controls.
• Collaborate on regulatory audits, findings responses or enforcements by regulatory agencies.
• Responsible to write Corrective Action Plans and comprehensive summaries
• Knowledge of DMHC, DHCS, CMS, Title 22 CCR, Title 28, Title 42, and Medi-Cal, Medicare processing guidelines
• Ability to effectively communicate with internal and external associates
• Responsible for reviewing criteria on denial letters
• Responsible to handle multiple audits and able to prioritize workflow

Your Knowledge and Experience

• Current CA LVN License

• Bachelors of Science in Nursing or advanced degree preferred

• Requires at least 3 years of prior relevant experience in auditing of claims, credentialing, or recredentialing

• Experience in auditing utilization management or prior out-patient authorization review preferred

• Desired knowledge of accreditation entities and their requirements
• Ability to work independently
• Excellent verbal and written communication skills and interpersonal skills
• Computer ease & literacy with Word, Excel, Power Point 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.