SHIFT: Day Job
Your Talent. Our Vision. At AIM Specialty Health (AIM), a proud member of the Anthem, Inc. family of companies, 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.
RN Quality Evaluator Senior
Preferred Location: Chicago, IL
Open to any office location for most qualified applicant
Position will be remote until COVID-19 restrictions are lifted
The Quality Evaluator Senior is responsible for supporting clinical audits, preparing trend reports and making process improvement recommendations to management.
Primary duties may include, but are not limited to:
Responsible for ensuring program integrity by establishing an audit process that is efficient and effective in monitoring case determinations, and compliance with Federal, State laws and regulations, CMS, OIG, as well as contractual obligations.
Responsible for conducting random case audits across solutions and providing management with a monthly report on the case audits.
Develops and reports the case audit performance scorecard results to Senior Director.
Reviews audit findings and follows up on errors identified during the audit process and identifies process improvements
May perform quality evaluations.
Requires a BS/BA in nursing, social work, respiratory therapy or related clinical field; 5 years of experience in managed care including progressive experience in clinical staff development and education, quality; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in applicable state(s) required.
Clinically relevant certification (i.e. Certified Diabetes Educator, Certified Case Manager) and a background in quality or performance improvement preferred.
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.