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Anthem, Inc Oversight Compliance Cnslt Sr PS26238 in West Des Moines, Iowa

Oversight Compliance Cnslt Sr PS26238

Location: United States

Requisition #: PS26238

Post Date: Aug 15, 2019

Responsible for serving as point of contact, coordinating and collaborating primarily with delegated entities and internal health plan functional units to ensure compliance with regulatory, accrediting and health plan quality of care and service requirements. Promotes and maintains favorable working partnerships and relationships with delegated entities, physicians, healthcare service providers, and internal customers to improve delivery and quality of health care. Primary duties may include, but are not limited to: Performs annual and ad hoc delegation oversight audits and internal health plan fuYour Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.

Clinical Compliance Consultant Senior

Location is Work At Home

Hours are core business hours, Central Standard Time

Responsible for supporting clinical regulatory compliance for a state, delegated entities, or enterprise wide for designated lines of business through project leadership, technical oversight and risk identification and mitigation.

Primary duties may include, but are not limited to:

  • Serves as point of contact, coordinating and collaborating with regulatory bodies and business partners to ensure compliance with regulatory, accrediting and Health Plan quality of care and service requirements.

  • Assists with the interpretation of applicable laws and regulations.

  • Develops tools that assist in determining exposure to regulatory and/or accreditation risks.

  • Identifies opportunities to manage and mitigate those risks.

  • Works with business management areas to develop metrics for monitoring program objectives and policies and procedures that support compliance with regulatory and accreditation standards.

  • Compiles information related to quality improvement and compliance monitoring activities for internal use and external audits and maintains relevant records.

  • Provides guidance and oversight to business units to ensure ongoing regulatory or accreditation compliance and monitors corrective action plans relating to regulatory or accreditation compliance.

  • Makes recommendations to business unit partners for improvements or remediation to risk management, regulatory, and accreditation compliance programs.

  • Monitors development and use of metrics for regulatory compliance.

  • Monitors business unit initiatives relating to the development and implementation of a risk management program for utilization management activities.

  • Collaborates with enterprise quality team, enterprise care management, and other clinical teams on regulatory initiatives.

  • Creates audit tools, reports, standardized policies and procedures, and manuals.

  • Facilitates implementation of survey or regulatory recommendations.

  • Recommends new processes.

  • Trains associates on new and revised standards.

nctional unit audits. Develops corrective action plans and analyses of required program reports and internal performance measures. Acts as an operational expert and interventionist through communication, education, and design of programs and strategies to assist delegated entities and internal departments meet regulatory and accrediting standards, promote quality outcomes, and maximize resources. Develops training materials and conducts training and/or new hire orientation. Delivers timely and constructive coaching and feedback. Assists with planning and implementation of formal education sessions to external customers to address non-compliance issues. Takes lead with healthcare industry collaborations so as to enhance regulatory and accrediting compliance among constituents. Ensures that all policies and procedures are updated as legislation or accreditation standards change. Assists with standardization of procedures and documentation. Assists in problem-solving with delegated entities and internal constituents. Requires an AS/BS in nursing; 5 years of acute care, utilization management, quality management in a hospital and/or HM setting; 2 years of experience conducting oversight audits of delegated entities and/or ancillary providers; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license or LCSW in applicable state(s) required. Must have strong knowledge of managed care principles and delivery systems, the medical management process, accreditation and regulatory standards, delegated oversight processes, and workflow systems. May require some travel.


Requires a BS/BA

  • 5 years of related professional experience

  • 3 years of regulatory, compliance, accreditation, and/or auditing experience

  • **or any combination of education and experience, which would provide an equivalent background.

  • RN preferred.

  • Ability to travel may be required, up to 25%.

  • Knowledge of clinical regulatory requirements such as experience with CMS and state regulatory and accreditation requirements preferred.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.