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Anthem, Inc. Sr. Behavioral Health Clinical Quality Audit Analyst in Anaheim, California


SHIFT: Day Job

SCHEDULE: Full-time

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.

Annual Salary Range*: $64,800 - $81,000

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

  • The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

    Responsible for participating in virtual and on-site quality external audits such as Delegation audits, annual claims and encounter audits and External Quality Review Organization (EQRO) activities and prepares audits of required documents.

    Primary duties may include, but are not limited to:

    • Provides recommendations for quality improvement studies including selection of valid and reliable indicators and coordinates monitoring and evaluation activities upon select implementation.

    • Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with Company procedures.

    • Defines opportunities for improvement through trend analysis and communicates information appropriately.

    • Assists in implementation and monitoring of quality studies including, but not limited to the development and implementation of behavioral health outcomes improvement interventions such as newsletter article, member education and outreach interventions, provider education and outreach interventions, medical record review, focus studies and surveys. Performs monthly, quarterly, annual and ad hoc medical record reviews such as HEDIS and CPG compliance.

    • Conducts quality of care investigations and using criteria closes case appropriately or refers to BH Medical Director for further review.

    • Prepares cases for Peer Review Committee.

    • Tracks and compiles audit recoupments and compiles the monthly and semi-annual Fraud, Waste, Abuse (FWA) report.

    • Assists in the coordination of the annual Health Services Advisory Group (HSAG) external quality review audit.

    • Maintains policy and procedure grid and updates policies and procedures when needed.

    • Tracks survey responses, analyzes and trends data

livery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.


Minimum Qualifications

  • Requires MS/MA degree in behavioral health or related field and a minimum of 3 years’ experience in quality improvement and/or behavioral health, risk management and/or utilization review in a managed care setting as well as process improvement; or any combination of education and experience which would provide an equivalent background. Specific education, type of experience and/or licensure may be required based upon contract requirements and delegated responsibilities.

    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.

    Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at 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.

    REQNUMBER: PS60595