Anthem, Inc. Clinical Quality Analyst (W@H) $5K Sign-on Bonus in Reston, Virginia
SHIFT: Day Job
Your 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 care companies and a Fortune Top 50 Company.
Location: This is an ‘off-premise-work’ (OPW) or Work-at-Home (W@H) position, however, associate must be willing to go to an office location as necessary, and must live within a 1 hour distance from a local office. To W@H selected candidate must have a dedicated room or location in home to be set-up as a private, secure location to allow for compliance with HIPAA regulations. Training is virtual and last approximately 2 – 3 months, with an expectation to be independent with all activities at the completion of the 3rd month.
Schedule: The work schedule for this position is Monday - Friday; business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8 hour shift between those hours. Occasional week-ends may be required according to business needs.
Responsible for developing, conducting, and analyzing quality studies according to criteria developed by management, external review organizations, and other regulatory agencies.
Primary duties may include, but are not limited to:
Conducts provider on-site audits by researching provider clinical quality issues.
Works on issues of diverse scope in which the analysis of data requires evaluation of identifiable factors and in accordance with department standards.
Develops and monitors corrective actions.
Completes quarterly progress/performance reports.
Maintains hospital quality database via requests for information and questionnaires. Generates scorecards for each hospital.
Provides feedback to practitioners on performance.
Performing quality of care investigations for the Medicare and dual eligible Medicare/Medicaid plans enterprise-wide.
Quality of Care (QOC) complaints are components of a Member grievance expressing dissatisfaction regarding the clinical care received from a Health Plan’s contracted provider.
Researching provider clinical quality issues and member quality of care grievances, to include outreach to providers across all time zones; reviewing medical records and pertinent information related to the issue (e.g. claims records); extrapolates, and summarizing the investigation in written format and preparing case file for clinical quality MD peer-review.
Works on issues of diverse scope in which the analysis of data requires evaluation of identifiable factors and in accordance with plan Enterprise and department standards.
Documents and logs QOC grievance information on relevant tracking databases and mainframe systems.
Generates appropriate written correspondence to providers, members, and regulatory entities. Ensures that investigations are resolved timely to meet regulatory timeframes.
Performs other related duties as required.
Requires BA/BS in a health related field and minimum of 2 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in applicable state(s) required.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.