Clinical Quality Auditor, Quality Review- Consultant - RN

Your Role 

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.

Your Work 

In this role, you will: 

• Perform Utilization Management audits—primarily for the Appeals and Grievance Department—to 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

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.