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Anthem, Inc. Staff VP Complex & Clinical Audit in Columbia, South Carolina


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.

Job Summary:

Responsible for the management and performance of complex and clinical audit programs for Government and Commercial clients.

Primary duties may include, but are not limited to:

  • Innovates, develops, and promotes new reimbursement and contracting policies to create cost effective FWA (Fraud, Waste and Abuse) controls and develop products and capabilities.

  • Develops and administers enterprise wide strategies for clinical editing and payment policy and communication of provider strategies to internal audiences.

  • Ensures clinical operations are meeting service level agreements and adhering to established processes and regulatory requirements.

  • Interfaces with the health plans and provides information regarding high risk areas of waste and abuse.

  • Serves as a resource and consultant to other areas of the company.

  • Develops complex and clinical industry-leading, and able to be commercialized, product line leveraging FWA advanced analytics development to drive cost optimization.

  • Influences industry best practice physician, hospital and ancillary reimbursement methodologies, anticipate market shifts, support growth initiatives, and support clinical strategies.

  • Communicates to providers best practices and opportunities for improvement to provide education and reduce abrasion.

  • Facilitates the communication of activities, emerging trends, and best practices across all business units and facilitates implementation of initiatives.

  • Collaborates with senior leadership to develop end-to end strategies and tactics that improve payment accuracy and reduce fraud, waste and abuse payment error.

  • Hires, trains, coaches, counsels, and evaluates performance of direct reports.


  • Requires a BA/BS degree.

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

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

  • M.D. or D.O. preferred,

  • Board certification or other clinical professional designation preferred; experience driving advanced analytics solutions and/or commercialized product development for multi-payer clients.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.