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Quality Evaluator - Remote - P...


Job Summary

Indianapolis, IN
Other/Not Classified
Job Type
Full Time
Career Level
Experienced (Non-Manager)
Job Reference Code

Quality Evaluator - Remote - PS4390

About the 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 benefits companies and a Fortune Top 50 Company.

The Quality Evaluator is responsible to monitor and evaluate clinical and non-clinical staff by performing quality assurance reviews on post-payment and pre-payment claim reviews for correct coding conventions based on what is documented in the member's medical record. Analyzes individual and overall trends based on monitoring results and providing recommendations to operations management or learning and Development. Serves as the subject matter expert in the areas of clinical and non-clinical policies and procedures, use of Facets, WGS, NASCO, FEP, CS90, Macess, WCF, Provider Reimbursement Policies, and Provider Contracts. Provides quality review process training.

Primary duties may include, but are not limited to:

  • Utilize multiple systems and tools to effectively evaluate review and audit decisions and documentation based on quality guidelines, clinical criteria, reimbursement policies, coding standards, departmental procedures and established performance standards.
  • Provides written and/or verbal feedback to program staff to assist with performance improvement and staff development
  • Ensures that both utilization and quality programs meet criteria.
  • Collects and analyzes data to formulate recommendations and solutions based on audit trends and results.
  • Compiles, maintains, and interprets statistical data.
  • Develops reporting and overall performance trend identification.
  • Prepares reports for management that define and evaluate problems and propose solutions.
  • Identify and collaborate with management to fix broken processes
  • Quality Assurance, Systems, Concept, and Refresher training
  • New Concept development and refinement

  • Requires a BS/BA in nursing, social work, respiratory therapy or related clinical field; 3 years of experience in managed care to include experience in clinical staff development and education, quality; or any combination of education and experience, which would provide an equivalent background.
  • Current unrestricted license in applicable state(s) for designated field (i.e. RN, Social Work, and Respiratory Therapy) required.
  • Medical Coding certification required.
  • Medical Coding Specialty Certification preferred.
  • 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 is a 2017 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.

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