• Connecticut

Anthem - QM Clinical Field Reviewer

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.

This QM Clinical Reviewer is part of the Medicare Quality-East team. You will meet with providers in our network throughout the state of CT. When not in the field, you will work at the Wallingford, CT office.

The QM Clinical Reviewer is responsible for performing comprehensive identification and documentation of burden of illness and ensuring aggressive closure of all known gaps in care to reduce avoidable episodes of care in support of the Medicare Quality Management Risk Adjustment program. This role is external facing, engaging and educating providers on clinical document process improvements and addressing gaps in care in order to drive effective and efficient utilization that improves medial management.

Responsibilities may include, but are not limited to:

  • Serves as a resource and subject matter expert on CMS-HCC Risk Adjustment Model.

  • Engages and educates providers about the value of the program and content of reporting.

  • Performs comprehensive review of medical information, identifies and collects determinants of member health, identifies and documents gaps in care, assists health care analytics in providing critical analysis of the collected information and provides appropriate reporting of analyzed data to providers.

  • Reviews medical records for under reported, under documented and undocumented burdens of illness and gaps in care.

  • Ensures proper assignment of ICD-10 codes to identified conditions.

  • Engages and educates members of the Quality Management Medical Reviewer team, other areas of the company and external stakeholders.

Requires 3 years clinical practice, prior chart review, clinical coding experience; or any combination of education and experience, which would provide an equivalent background. 2 years of experience as a medical chart reviewer preferred. Foreign medical graduate or foreign physician preferred.

  • Must know Medicare Risk Adjustment.

  • Experience meeting with and influencing providers preferred.

  • Must have excellent communication skills.

  • Must have a reliable vehicle to travel to providers (mileage reimbursed).

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 antheminc.com/careers.

An Equal Opportunity Employer/Disability/Veteran

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