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Compliance Audit Services Specialist, Senior

Company: Blue Shield of California
Location: Monterey Park
Posted on: March 21, 2020

Job Description:

At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!


Compliance Audit Services, Specialist, Senior

Responsible for performing regulatory/contractual delegation oversight control audits to ensure compliance with Federal and State regulatory agencies. Assures compliance to external specifications and standards. Conducts comprehensive regulatory reviews using a standard audit model.


  • Includes monitoring and review of self-reported compliance, developing an audit plan, executing the audit, identifying corrective action opportunities, creating a final report, and following up on outstanding issues.

  • Responsible for monitoring and reporting operational timeliness of delegated providers and other delegated entities to assure compliance to federal and state regulatory requirements and standards including but not limited to Blue Shield Promise contractual specifications and standards.

  • Responsible for instituting corrective action for non-compliance. Negotiates corrective action plans.

  • Participates in the development of training. Develops correspondence to external entities.

  • Coordinates auditing process with external providers and internal business units.

  • Manages internal & external data reporting on compliance, interdepartmental performance reviews, and monthly claims delegation compliance reviews.

  • Responsible for revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers.

  • Participates in projects and taskforces as assigned.

  • Responsible for making moderate to significant improvements of processes, systems or products to enhance performance of job area.

  • Other duties as assigned.


    • Issues faced are numerous and undefined, and 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. Develops new perspectives and innovative approaches on existing problems.


      • Communicates with parties within and outside of own job function.

      • Has responsibility for communicating with parties' external to the organization (e.g., customers, vendors, etc.).

      • Works to influence parties within and outside of the job function at an operational level regarding policies, procedures and practices.


        • Generally, responsible for providing guidance, coaching and training to other employees within job area.

        • Generally, responsible for managing major/complex projects involving delegation of work and review of work products.


          • Requires a college degree or equivalent in managed Health Care experience with a minimum of 5 years

          • 5 years' experience in claims, health care auditing and operational compliance,

          • Extensive knowledge of DMHC, DHCS and CMS regulatory requirements and guidelines, Viewed as a subject matter expert within claims and operational compliance.

          • Excellent analytical and problem-solving skills.

Keywords: Blue Shield of California, Monterey Park , Compliance Audit Services Specialist, Senior, Accounting, Auditing , Monterey Park, California

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