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Clinical Quality Audit Analyst Sr. - Pine St., NYC - PS11941 in New York, NY at Anthem, Inc.

Date Posted: 10/10/2018

Job Snapshot

Job Description

Your Talent. Our Vision. At Empire Blue Cross Blue Shield, a proud member of the Anthem, Inc. family of companies,  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. 

This is an office based position at the 9 Pine St. office of Empire BCBS. You must have a clinical license. You will be the NY health plan representative for Medicaid Fair Hearings. You should have knowledge of this process, as well as UM and Appeals exp.
The Clinical Quality Audit Analyst is responsible for the coordination and oversight of the appeals process. Will review clinicals of medical necessity auth. denials, work closely with the health plan Medical Director, and document results according to specific contractual timelines.
Primary duties may include, but are not limited to:
-Designs and implements quality improvement studies.
-Analyzes data and prepares quality management reports in accordance with QM principles.
-Participates in intra-departmental teams to improve sustainable member outcomes; assists in defining opportunities for improvement identified through analysis of trends.
-Coordinates resolution of high level complaints.

Requires an RN/LPN/LVN; minimum of 2 years of experience in quality improvement, risk management and/or utilization review in a managed care setting; or any combination of education and experience, which would provide an equivalent background.
-Current, active, unrestricted RN, LPN, or LVN license in NY required.
-Knowledge of the NY Fair Hearings process for Medicaid preferred.
-Utilization Management and Appeals experience preferred. 
-Computer skills: MS Word, Excel, Outlook; Facets, Care Compass a plus.
This is a clinical operations position requiring excellent verbal/written communication skills, attention to detail, excellent organization skills and ability to meet strict deadlines.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at
Equal Opportunity Employer/Disability/Veteran.