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Anthem, Inc. Staff VP Program Integrity Provider Audit in Watertown, Massachusetts

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 benefits companies and a Fortune Top 50 Company.

Location: Any Anthem Office

Job Summary:

The Staff VP of Provider Audit is a leadership role responsible for managing the Provider Audit and Provider Education programs within the Program Integrity division of Anthem’s Diversified Business Group (DBG). The successful candidate will have extensive business transformation and organizational change experience, as well as people management skills to be equipped to work with the Vice President of Program Integrity along with peer Staff Vice Presidents and associates to advance the following business objectives:

  • Provide leadership and oversight to deliver a 200%+ improvement in cost of care savings within 12-18 months, while improving the operating structure:

o Implement programs to elevate productivity and standardize audits.

o Identify and evaluate new and existing concepts and opportunities to deliver cost of care savings.

o Create a performance-based culture of delivery excellence, financial transparency and team accountability.

o Expand prevention and pre-payment clinical and complex programs including growing provider education change in behavior programs.

o Increase use of advanced analytics to cost effectively expand lead identification.

o Hiring the right mix of talent to scale the Provider Audit team to meet growing demand and potential commercialization effort, such as building out a BPO service.

  • Cultivate and manage demand from Anthem health plans, national accounts, and other clients to deliver value through services:

o Develop an understanding of health plan and national account needs to craft relevant Provider Audit services.

o Work with Product & Efficiency to ensure emerging needs are addressed with Information Technology solutions and Business Services.

o Support commercialization initiatives to bring Provider Audit solutions to market overtime to serve both Anthem and other clients

Participates in developing strategic direction for clinical reimbursement programs to foster elimination of fraud, waste, and abuse. Defines audit concepts to meet grow incremental cost of care value by 20-30% each year. Oversees program design and workflow to operationalize and enhance management of overpayments to increase program savings.

Key Responsibilities:

  • Manage the Provider Audit department to ensure financial and operational performance goals are achieved.

  • Influence clinical policies to support program implementation and adoption.

  • Drive strategic direction of the Program Integrity Medical Director team and ensure strong partnerships with medical management.

  • Create a supportive culture that embraces new technologies and continuous process improvement.

  • Elevate performance for existing concept execution through standardization of business practices.

  • Streamline new concept creation to support effective expansion of Provider Audit to address emerging health plan needs.

  • Create and implement business plans to support scaling the department.

Qualifications

Required:

  • BA/BS degree.

  • 10+ years related experience in broad based analytical, managed care payer or provider environment; demonstrated clinical thought-leadership experience including auditing experience.

  • Excellent leadership, financial and operational skills required.

  • Any combination of education and experience which would provide an equivalent background.

Preferred:

  • 10 years of management experience with strong organizational change management background and provider audit experience or clinical documentation improvement experience.

  • MBA preferred.

  • M.D. or D.O.

  • Board certification approved by the American Board of Medical Specialties a plus.

  • Ability to travel may be required.

Desired Experience/Skills:

  • Experience managing Provider Audit or Clinical Documentation Improvement (CDI) departments.

  • Demonstrated ability to identify new programs and influence clinical policy to enable program success.

  • Decisive, quick on your feet, strong executive presence with the ability to drive operational performance and new program launches.

  • Demonstrated capacity and track record of acting with a sense of urgency to tactically evaluate, implement programs and initiatives and work with a variety of organizational leaders to build consensus.

  • Sound analytical thinking, financial planning acumen, prioritization, and process orientation and execution skills.

  • Collaborative mindset to work with cross-functional teams to develop solution-oriented products and partnerships.

  • Strong communication skills, with ability to develop compelling written communications, term sheets and presentations.

  • Proven experience managing multiple, competing priorities while flawlessly executing on driving deliverables and operational tasks.

  • Project management and lean six sigma experience preferred, but not required.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com An Equal Opportunity Employer/Disability/Veteran

REQNUMBER: PS40501

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