Anthem Inc. Medical Jobs

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Anthem, Inc. Clinical Quality Prog Admin/QI in Coconut Grove, Florida


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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.

Clinical Quality Program Admin (PS36931)

*This position sits in our Coconut Grove, FL office location and will not be considered a work at home

Summary: The Clinical Quality Program Admin is responsible for participating in quality improvement activities/projects as outlined in the Quality Improvement (QI) Program and work plan and assists in HEDIS and Star improvement activities, CMS mandated activities, and accreditation standard compliance.

Primary duties may include, but are not limited to:

  • Participates in the QI process of the health plan working closely with the QI & accreditation services lead.

  • Participates in HEDIS & Star measure initiatives that includes focused medical record review to identify non-standard supplemental data.

  • Assists in the conduct of clinical review of grievances to include documentation of written summaries of findings.

  • Conducts medical record review to assist in identification of gaps in care and compliance with clinical practice guidelines and preventive guidelines.

  • Participates in the clinical quality improvement activities/projects and assists in the implementation of appropriate clinical interventions to improve the quality of care and services for members.

  • Conducts on-going population assessment to ensure member educational activities are relevant to the member population.

  • Active participant in ensuring continued compliance of regulatory and accreditation standards.

  • Participates in the quantitative analysis of clinical data and presentation of results.

  • Assists in educational activities and in-servicing of the physician and other providers working with provider operations and the integrated delivery network staff.

  • Conducts monitoring of medical documentation and outcomes to ensure physician and provider compliance with clinical practice guidelines and preventive health guidelines.

  • Participates in the annual HEDIS project with the QI Department.

  • Ensures maintenance of the achievement of Dual Special Needs Plan (D-SNP) goals and appropriate documentation as required by CMS.

  • Participates in required QI activities as outlined in the D-SNP Model of Care.



  • Requires a BS in health administration, nursing or related clinical field; minimum 3 years of health care quality or data analysis experience; or any combination of education and experience, which would provide an equivalent background.

  • Current certification in applicable field preferred (i.e. CPHQ).

  • MS in the health field (i.e. Nursing) preferred.

  • Strong Medicare experience preferred.

  • Experience in QI preferred.

  • Demonstrated analytical skills.

  • DSNP and Dual Enrollment experience preferred.

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 An Equal Opportunity Employer/Disability/Veteran.