Clinical Quality Auditor, Consultant chez Blue Shield of California Group

Your Work

In this role, you will:

• Perform Behavioral Health audits for Utilization Management, Care Management, and Post Service.
• Review audit data to identify care gaps, compliance risks, and trends
• Communicate findings to leadership and provide recommendations to mitigate risks
• Act as subject matter expert to review and evaluate the effectiveness of operational workflows to identify problems and develop improvements, modifications, and enhancements
• Develop and evaluate tools and materials that enhance operating efficiency, accuracy, and technical skill levels of unit staff
• Assist with audit readiness in collaboration with internal BSC partners
• Design, implement, evaluate and improve audit criteria and coaching strategies to meet the needs of the Behavioral Health teams
• Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work
• Conduct effective presentations relating to Behavioral Health processes and/or regulatory compliance for clinical staff
• May independently represent the Quality Review department in Behavioral Health work re-design, process changes, and software implementation
• Act as a resource for the training and auditing team

Your Knowledge and Experience

• A college degree or equivalent experience and minimum and 7 years of prior relevant experience required.
• Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required.
• At least 5 years of experience in managed care or similar Behavioral Health healthcare environment preferred
• Auditing experience preferred
• Familiarity with Mental Health/Substance Use Disorder (MH/SUD) Non-Profit Criteria preferred (CALOCUS, LOCUS, ASAM)
• Knowledge of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay clinical against nonprofit association guidelines
• Familiarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab results
• Strong organizational and/or project management skills to coordinate departmental projects and to perform multiple projects or tasks simultaneously
• Subject matter expert with capability to effectively audit and train all lines of business (Commercial, Federal Employee Program, Medicare, and Medi-Cal)

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.