Skip to main content

QM Regulatory Review Analyst

  • Job Family: Fraud
  • Type: Full time
  • Date Posted:
  • Req #: JR37929


  • FL, Miami



Location: Miami, FL

How you will make an impact:
This role will monitor SLAs, metrics, CMS claims processing guidelines.  This associate will be responsible for reviewing/revising policies and procedures, directly working with compliance, preparing universes for CMS audits, presenting during audits, and completing quality monitoring of Claims department provider and member communications. Responsible for ensuring regulatory compliance through active monitoring of plan operational performance.

Primary duties may include, but are not limited to:

  • Assists in quality assurance/improvement issues.
  • Communicates regulatory changes affecting SBU.
  • Coordinates audit activities and develops procedures to monitor policy and procedure updates.
  • Interfaces with internal partners to support/identify issues and improvement and cost saving opportunities.
  • Conducts regulatory training and provides guidance on compliance matters.
  • Performs oversight and analysis and activity coordination.

Minimum Requirements:

  • Requires a BA/BS degree.
  • Minimum of 3 years' experience in healthcare insurance, medical accreditation, or government regulations.
  • Any combination of education and experience, which would provide an equivalent background. Travel is required. Detail orientated and able to meet deadlines strongly preferred

Preferred, Skills, Capabilities, and Experiences:

  • Medicare experience, preferred.
  • Degree in healthcare field, preferred.
  • Bilingual, Spanish and English, preferred.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

Apply Now