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QM Acred/Reg Review Analyst or Senior

Anthem, Inc

This is a Full-time position in Fresno, CA posted December 9, 2020.

Description SHIFT: Day JobSCHEDULE: Full-timeYour 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.Quality Management Acred/Regulatory Review Analyst or SeniorLocation: This position can be located at Any Anthem Office Location (once offices reopen)Please Note: This position may be filled at either the Quality Management Acred/Regulatory Review Analyst or Analyst Senior level.

Manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.” Responsible for all L (life & disability) lines of business appeals, DOI Inquiries, any Legal inquiry (subpoena, records requests, subrogation) and coordinates with the Anthem Legal Team on gathering records, serving as the point person for Claims for any questions on policy or procedure and claim handling in addition to assisting with calculations in conjunction with Actuarial to determine financial liabilityPrimary duties may include, but are not limited to: + Provide the Anthem Legal Team (and assigned external law firm) copies of all records related to the claim(s) involved.

+ Assist in responding to inquiries as to process and policy.

+ Review and sign Declarations related the claim documents used in the claim determination and provided for evidence.+ Ensuring compliance with ERISA regulations and timeframes.+ Compliant with State’s required investigation response and reply within the designated timeframe.

And, coordinate reporting with Specialty Compliance.+ Participates in Quality Management (QM) activities that ensure program meets regulatory standards.

+ Prepares department for oversight audits and ensures that regulatory developments are communicated timely where appropriate and with all applicable parties.

+ Maintains oversight of corrective action plans in response to areas of non-compliance.

+ Develops and ensures compliance program meets its stated objectives; provides subject matter expertise in response to day to day business issues; researches applicable subject matter practices and remains aware of industry trends; manages relationships and partners with corporate and regional business areas and coordinates training related to compliance program.

+ Coordinates flow of information and documentation between associates responsible for day-to-day activities related to accreditation or regulatory reviews.

+ Develops and implements accreditation/ regulatory review tracking system.

+ Maintains regulatory review compliance library.

+ Creates audit tools, reports, standardized policies and procedures+ Facilitates implementation of survey or regulatory recommendations.

+ Assess and evaluate progress towards meeting regulatory standards.

+ Recommends new process if necessary.

+ Trains associates on new and revised standards.

+ Compiles documentation for presentation to accrediting/regulatory organization.

Qualifications + BA/BS in business or a related field preferred;+ 3-5 years in either Life or Disability insurance; experience in a healthcare setting with 3 years quality management experience; experience preparing for regulatory audits and knowledge of regulatory standards; or any combination of education and experience, which would provide an equivalent background.+ CPDM, GBDS preferredREQNUMBER: PS43156