Clinical Compliance Medical Director

at Anthem, Inc in Wilmington, Delaware, United States

Job Description


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. Responsible for providing clinical compliance guidance related to the company’s Medicare Risk Adjustment coding guidelines, provider coding audits, prepare and deliver clinical training, and participate provider investigations focused on potential MRA related fraud, waste and abuse in the provider population. This role sits in Medicare Compliance. Primary duties may include, but are not limited to:

+ Reviews provider medical record documentation to determine if there is potential fraud, waste, or abuse that warrants further investigations.

+ Conducts provider interviews related to these investigations.

+ Reviews investigative material which includes provider medical record documentation.

+ Provides clinical guidance regarding coding guidelines and develops provider educational material.

+ Develops a more clinically focused provider audit process to obtain more meaningful results.

+ Develops clinical review for investigations team including developing guidelines on how to implement the clinical analysis portion of the investigations and developing clinically relevant questions for provider interviews.

+ Develops provider educational materials that are clinically focused and provides peer-to-peer compliance training and education to other providers internally and externally.

+ Provides input to provider reporting from the provider perspective.

+ Serve as clinical compliance expert as it relates to MRA, coding, medical record, documentation for Anthem and its subsidiaries.

+ Assess clinical components of new or changing MRA programs.

+ Provide input and assist with developing a more clinically focused provider audit process to obtain more meaningful results


Required Qualifications:

+ Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).

+ Requires active unrestricted medical license to practice medicine or a health profession.

+ Clinical training and practice as a primary care physician required.

+ Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.

+ Medicare Risk Adjustment experience preferred

+ Medical coding certification (AAPC or AHIMA).

+ Travel may be required.

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. REQNUMBER: PS63779
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Job Posting: JC198082172

Posted On: Nov 20, 2021

Updated On: Dec 21, 2021