Anthem, Inc. Oversight Compliance Consultant Senior- Any Anthem Location in CA in San Jose, California
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: Any California Anthem Core Office Location, Woodland Hills, CA preferred (once offices reopen) Hours are core business hours
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 functional 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 utilization management, regulatory, compliance, accreditation, quality management and/ or auditing experience in a hospital and/or managed care setting or any combination of education and experience, which would provide an equivilant background,
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, preferred.
Current unrestricted RN license 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.
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. An Equal Opportunity Employer/Disability/Veteran
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.