Hempstead, NY, United States
Compliance, Consulting, Nursing, Healthcare
Clinical Compliance Consultant Sr - Medicaid - REMOTE (RN Compact License preferred) (PS22330)
Location: United States
Requisition #: PS22330
Post Date: 5 hours ago
Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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.
Preferred Location : Work@home in Iowa.
Other Locations : This is a work@home position. Candidates may work remotely but must be able to work Central Standard Time – business hours.
The Clinical Compliance Consultant Sr. is responsible for reviewing quality of care issues / critical incidents / clinical grievances to ensure member well-being. Supports 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/leads associates on new and revised standards.
Audits work of other associates.
BS/BA; 5 years’ experience in a social service or health related service industry reviewing quality concerns including 3 years of regulatory, compliance, accreditation, and/or critical incident auditing experience or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in the state where you reside is required.
Managed Care Industry experience.
Quality Management experience.
Knowledge of clinical regulatory requirements such as experience with CMS and state regulatory and accreditation requirements preferred.
Critical Incident Audit experience.
Certified professional Coder 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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.
Website : http://www.antheminc.com
The company was formed when WellPoint Health Networks Inc. and Anthem, Inc. merged in 2004 to become the nation's leading health benefits company. The parent company originally assumed the WellPoint, Inc. name at the time of the merger. In December 2014, WellPoint, Inc. changed its corporate name to Anthem, Inc. The Anthem brand is built on a foundation of trust – it’s the name consumers are most familiar with as a trusted health care partner through our affiliated health plans. Anthem, Inc. is one of the largest health benefits companies in the United States. Through its affiliated health plans, Anthem companies deliver a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts. Headquartered in Indianapolis, Indiana, Anthem, Inc. is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin; and specialty plan members in other states.