Delegation Oversight Clinical Nurse Auditor - LVN, Senior

Your Role

The Delegation Oversight Compliance team is responsible for working with appropriate departments in the areas of compliance, process improvement, and member/provider satisfaction for all product lines. Reviews, research and responds to customer complaints relating to quality of medical care and service. Recommend and/or implement process improvements related to the potential quality of medical care and service. The Delegation Oversight Clinical Nurse Auditor – LVN, Senior, will report to the Delegations Oversight Compliance Manager.

The Clinical Nurse Auditor - LVN, Senior is responsible for independently conducting comprehensive delegation oversight audits to evaluate delegated entities' compliance with the California Department of Managed Health Care (DMHC) All Plan Letter (APL) 24-019, Rule 1300.67.2.2. The position conducts regulatory compliance assessments of delegated medical groups, Independent Practice Associations (IPAs), Management Services Organizations (MSOs), and other contracted entities to ensure the accuracy, completeness, and reliability of information provided to the health plan for regulatory oversight.

As a senior-level auditor, this position independently manages complex audit assignments, evaluates regulatory risks, develops audit findings, monitors corrective actions, and provides technical guidance to delegated entities. The position supports the organization's regulatory readiness and accountability for delegated functions.

Responsibilities

In this role, you will

• Oversee delegated groups and vendors' policies, procedures, utilization management, and related activities.
• Monitor compliance with APL 25-019 out-of-network provider access requirements, including Letters of Agreement (LOAs), Memoranda of Understanding (MOUs), and concierge services. Perform on-site and virtual audits.
• Independently plan, coordinate, and perform annual, focused, and for-cause audits to assess delegated entities' compliance with applicable APL 24-019 requirements.
• Assess delegated policies, procedures, workflows, and internal controls that support Annual Network Reporting.
• Substantiate compliance findings through document reviews, data validation, sampling, and interviews.
• Detect regulatory deficiencies, operational gaps, and systemic compliance risks.
• Document clear, accurate audit findings supported by evidence.
• Link each deficiency to the applicable regulatory, contractual, or organizational requirement.
• Review delegated entities' corrective action plans.
• Assess root-cause analyses and proposed corrective actions.
• Track corrective action implementation and completion deadlines.
• Referring recurring findings, unresolved deficiencies, and material regulatory risks to management for escalation.
• Keep audit and corrective action records complete and accurate.
• Produce audit reports detailing findings, supporting evidence, regulatory references, and required corrective actions.
• Examine delegated groups' reports to verify compliance with specific regulations.
• Partner with Blue Shield staff on regulatory audits, corrective action plans, and regulatory agency enforcement actions.
• Provide medical groups/IPAs with education on changes to regulatory requirements and/or accreditation standards.
• Familiarity with DMHC APL 24-019, Rule 1300.67.2.2, and Annual Network Reporting requirements is preferred.
• Understand auditing practices for delegated medical groups, IPAs, or MSOs.
• Pursue operational targets that directly affect departmental results.
• Operate independently with limited supervision.
• Work is reviewed to determine whether it meets objectives.
• May assume full responsibility for projects or processes within the role's scope.
• Perform additional duties as assigned

Qualifications

Your Knowledge and Experience

• High School Diploma/GED and completion of a state-approved Vocational Nursing (LVN) program
• Current unrestricted CA LVN License
• 5 years of prior relevant experience
• Strong critical thinking, analytical, and problem-solving skills

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.