Facility Site Review Clinical Nurse Auditor, RN

The Health Care Quality and Affordability team is made up of about 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision – to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health Care costs to ensure all Californians have access to the care they deserve.

How do we do it? Through partnership, innovation, and thought leadership.

We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You’ll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield mission.

Position Summary:

The Facility Site Review (FSR) Clinical Nurse Auditor, RN surveys primary care provider (PCP) sites to ensure there is sufficient capacity to provide appropriate primary health care services, carry out processes 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. The FSR Clinical Nurse Auditor, RN assists in preparing for and participating in external audits with regulatory bodies such as DHCS, DMHC, CMS, NCQA and LA Care.

Specific Responsibilities Include:

• Performs Facility, Medical Record and other provider reviews in accordance with FSR regulatory requirements.
• Conducts provider surveys, issues findings reports and requests Corrective Action Plans (CAP) as necessary.
• Tracks and follows up on CAPs and other information to be submitted to the Plan, to ensure evidence of corrective actions are in place.
• Acts as a liaison and provides support and resources to providers to assist in completing required corrective actions.
• Ensures all review documentation is completed, organized and entered into the program data system per established timeliness.
• Receives site assignments from FSR Lead, RN and schedules audits per established department timeframes.
• Participates in a team of nurses, auditors and coordinators in all audit activities. Ensuring program activities are conducted timely.
• Maintains oversight and reviews quality of Clinical Nurse Auditor, LVN activities such as collection of Corrective Action Plan (CAP) documentation.
• Reports any instances of noncompliance, such as access issues or quality concerns to the assigned Lead, RN or Manager for forwarding to appropriate department.
• Attends staff training, staff meetings and/or offsite meetings as needed.
• Participates in department participation in regulatory audits.
• Participates in workgroups/special projects for department as assigned.
• Works independently under limited supervision.
• Trains internal staff as needed.
• Maintain current or achieve a passing inter-rater score of 10% or less for, DHCS Certified Site Reviewer certification required.
• Maintains specialized certification as appropriate.
• Other duties as assigned.

Minimum Education & Experience Requirements:

• Registered nurse with a current, valid license in California
• A minimum of an Associate’s degree or other equivalent experience
• A minimum of 3 years clinical experience
• Prior Quality Improvement experience, preferably in a Health Plan or IPA setting
• Health Plan and/or clinical management highly desired

Preferences:

• Bachelor’s degree preferred
• DHCS Certified Site Reviewer or eligible to be certified within 6 months of employment
• Expertise in Microsoft Office (Word, Excel, Outlook)

KNOWLEDGE and SKILLS:

• Must possess excellent written and verbal communication skills
• Must have excellent organizational skills
• Medi-Cal Managed Care knowledge
• Current California driver’s license, and car insurance required