/ 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 care for our members, greater value for our customers and greater health for our communities. Join us and together we willdrive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Location:Nashville, TN office until training complete.
TheClinical Compliance Consultant Sr. is 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/leads associates on new and revised standards.
Audits work of other associates.
BS/BA; 5 years of professional experience 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 of Tennessee.
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 2015 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at / / antheminc.com/careers //. EOE. M/F/Disability/Veteran./
Title: Medicaid Compliance Audit Consultant Sr (RN) - Nashville, TN (123194)
Requisition ID: 123194
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