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Clinical Compliance Consultant Sr

Location: Norfolk, VA
JobFamily: Fraud
Req #: PS61455
Date Posted: Jan 31, 2022

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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.

Location: Remote near an Anthem office.  

The Clinical Compliance Consultant Sr. is responsible for supporting medical, behavioral, and pharmacy claims regulatory compliance for contracted delegated entities, for designated lines of business through project leadership, technical oversight and risk identification and mitigation.

Primary duties may include, but are not limited to:

  • Serves as point of contact, coordinating and collaborating with regulatory bodies and business partners to ensure compliance with regulatory, accrediting and Health Plan quality of care and service requirements.
  • Assists with the interpretation of applicable laws and regulations.
  • Routine monthly/quarterly ODAG monitoring of claims delegated entities.
  • Facilitates the performance of the pre-delegation and annual performance audits of medical, behavioral, and pharmacy claims delegated entities.
  • Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement.
  • Develops corrective action plans when deficiencies are identified, and documents follow up to completion.
  • Identifies opportunities to manage and mitigate those risks.
  • Works with business management areas to develop metrics for monitoring program objectives and policies and procedures that support compliance with regulatory and accreditation standards.
  • Compiles information related to quality improvement and compliance monitoring activities for internal use and external audits and maintains relevant records.
  • Provides guidance and oversight to business units to ensure ongoing regulatory or accreditation compliance and monitors corrective action plans relating to regulatory or accreditation compliance.
  • Makes recommendations to business unit partners for improvements or remediation to risk management, regulatory, and accreditation compliance programs.
  • Monitors development and use of metrics for regulatory compliance.
  • Monitors business unit initiatives relating to the development and implementation of a risk management program for utilization management activities.
  • Collaborates with enterprise quality team, enterprise care management, and other clinical teams on regulatory initiatives.
  • Recommends new processes.




  • Requires a BS/BA; 5 years of professional experience including 3 years of regulatory, compliance, accreditation, and/or auditing experience or any combination of education and experience, which would provide an equivalent background. 
  • Ability to travel may be required.

Preferred qualifications

  • Knowledge of medical, behavioral, and pharmacy claims regulatory requirements such as experience with CMS compliance, and state regulatory and accreditation requirements preferred.
  • Medicare Managed Care claims processing experience related to delegation oversight and auditing, reporting-Part C, monthly timeliness, etc. 

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.

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.