Job Description

Clinical Quality Auditor, Consultant

The Quality Review team completes audits of front-line staff to ensure alignment with department processes and regulatory compliance. Clinical Quality Auditors also provide coaching and work closely with business leaders to drive optimal results. The Clinical Quality Auditor, Consultant will report to the Quality Review Senior Manager. In this role you will develop performance metrics, evaluate performance, and perform auditing and coaching to ensure that staff have the skills and knowledge required to be successful in Utilization Management and Appeals and Grievance (Post Service).

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

In this role, you will:

• Perform Utilization Management auditsprimarily for the Appeals and Grievance Departmentto assess accuracy, compliance, and adherence to established processes
• Analyze audit findings to identify care gaps, compliance risks, operational trends, and opportunities for improvement
• Communicate results and present actionable recommendations to leadership to mitigate risks and enhance performance
• Act as a subject matter expert by evaluating operational workflows and recommending improvements, system enhancements, or process redesigns
• Develop, refine, and evaluate tools, training materials, and resources that improve operating efficiency, audit accuracy, and staff technical competencies
• Lead or support audit?readiness activities in partnership with internal Blue Shield of California teams
• Design, implement, and enhance audit criteria, coaching strategies, and evaluation methods aligned with Medical Management team needs
• Provide developmental coaching and mentoring to strengthen staff skills, decision?making, and regulatory understanding
• Deliver effective presentations on Medical Management processes, audit trends, and regulatory compliance to clinical staff as needed
• Represent the Quality Review department in cross?functional initiatives, including Appeals and Grievance work redesign, process updates, and software implementations
• Act as a key resource and partner to training teams and auditing functions across the unit

Qualifications

Your Knowledge and Experience:

• Current, unrestricted California RN license required
• Requires a college degree or equivalent experience
• Requires 7 years of prior relevant experience
• Minimum 5 years of experience in managed care or a similar complex healthcare setting, including experience in Concurrent Review, Prior Authorization, or Post?Service Review
• Strong knowledge of Medicare and Medi?Cal requirements, with ability to audit and train across both lines of business
• Familiarity with regulatory agencies and standards, including DMHC, CMS, and NCQA
• Strong organizational and project management skills with ability to manage multiple priorities, lead department initiatives, and meet deadlines
• Demonstrated ability to coach and develop clinical staff on audit findings, regulatory requirements, and operational processes
• Prior auditing or quality review experience preferred
• Experience designing audit tools, performance metrics, or workflow improvement strategies preferred

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About Us

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

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• 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.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.

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