Your Role

The Clinical Compliance Principal, Medical Care Solutions is responsible for developing and maintaining the team's audit playbook for all lines of business for all regulatory and mock audits. Clinical Compliance Principal is also responsible for managing changing UM requirements driven by contractual changes or All Plan Letter requirements. The successful candidate will work with internal and external stakeholders understanding regulatory requirements, file preparation, letter and system accuracy, quality reporting, processes, and metrics. This role will own the regulatory and accreditation audit work plan for function by understanding workflows, operational procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). This position provides frontline support for nurses and coordinators and works in collaboration with leadership. The Clinical Compliance Principal works closely with subject matter experts for each line of business (LOB) to facilitate educational and change management processes as needed.

Your Work

In this role, you will:

• Develop new perspectives and innovative approaches on existing problems; require detailed information gathering, analysis and investigation to understand the problem. Problems are difficult and moderately complex, typically impact multiple departments or specialties, and are usually solved through drawing from prior experience and analysis of issues.
• Track and follow up on Corrective Action Plans (CAPs) and other information to be submitted to the Plan, to ensure evidence of corrective actions are in place.
• Provide expert consultation and practice oversight of regulation adherence.
• Design, develop and maintain an audit playbook and audit knowledge base repository; lead preparation and support for multiple regulatory audits annually, including audit universe and file prep.
• Facilitate file and audit practice sessions with internal stakeholders.
• Work with internal stakeholders to assure changing contractual and All Plan Letter (APL) requirements are incorporated into policies and procedures, as well as UM processes.
• Department owner for UM Policy and Procedure updates to maintain alignment with APL and contractual requirements.
• Generally, responsible for managing major/complex projects involving delegation of work and review of work products; participates in workgroups/special projects for department as assigned.
• Responsible for making moderate to significant improvements of processes, systems and products to enhance performance of job area.
• Works to influence parties within and outside of the job function at an operational level regarding policies, procedures and practices.

Your Knowledge and Experience

• Current CA RN License.
• Bachelors of Science in Nursing or advanced degree preferred.
• At least 10 years of prior relevant experience in health plan.
• Utilization Management experience highly preferred
• Experience with and strong working knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) and managed care for various lines of business (HMO, PPO, Medicare, Medi-Cal, Cal Medi-Connect)
• Excellent analytical and problem-solving skills
• Strong project management skills with multi-initiative leadership experience
• Strong verbal/written communication and organizational skills
• Ability to work independently in a fast-paced and fluid work environment
• Consistent demonstration of knowledge, skills, abilities, and behaviors needed to provide superior and culturally sensitive service to team members

Pay Range:

The pay range for this role is: $ 136400.00 to $ 204600.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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