Clinical Quality Advisor (Degreed)-Military OneSource
DescriptionSHIFT: Day Job
The Quality Evaluator Advisor is responsible for evaluating clinical and quality performance by monitoring calls and correspondence. Ensures the delivery of excellent service to internal and external customers. Ensures that management is apprised of critical service quality issues, that staff receives appropriate training and performance feedback, and management receives appropriate recommendations regarding staff development.
Primary duties may include, but are not limited to:
- Monitors, evaluates and documents member or provider calls for designated staff to ensure staff responses meet clinical and quality audit standards, and provides managers with call coaching quality data.
- Partners with the management team to ensure frequent performance and developmental feedback is provided to staff.
- Compiles and reports monitoring evaluation data and presents call coaching sessions.
- Provides staff with an action plan for process improvement, and if needed collaborates with management in the corrective action process by gathering documentation regarding non-compliance in meeting required standards. Contributes to performance improvement plans and participates in staff discussions.
- Ensures processes are in place to support compliance with all state and federal laws (HIPAA), regulatory requirements, accrediting agencies (NCQA and URAC) as well as clinical criteria and policies and procedures. Compiles and presents summary level call coaching and efficiency data.
- Assures integrity and confidentiality of call monitoring documentation and evaluates and develops monitoring tools to support efficiency and effectiveness in the call monitoring process.
- Audits the timeliness and accuracy of any contractual follow up inquiries.
- Measures the ability of staff to successfully meet all client performance expectations and presents final assessments to management.
- Identifies improvements or training opportunities and develops and presents quality improvement training materials to improve overall service quality.
- Identifies trends in inquiry monitoring and applies corrective actions as necessary to meet business needs. Ensures follow through staff. Develops ideas for performance improvement, service delivery, and cross-functional initiatives that contribute to department success.
- Collaborates with management on new client implementation activities, including development and presentation of training materials, to ensure all service center and client performance expectations are met.
- MS in Social Work or one of the core mental health disciplines; 5 years of post graduate clinical/administrative experience; or any combination of education and experience which would provide an equivalent background.
- US Citzenship
- Prior military experience or military affilation
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 careers.antheminc.com. 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.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.