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Manager, Clinical Content & Reimbursement

Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Manager, Clinical Content & Reimbursement(Provider Reimbursement Manager) is responsible for driving the development and execution of the clinical content scope in alignment with the product and content strategy to meet financial and operational targets. You'll research and interpret CMS, CPT/AMA and other major payer policies based on medical coding and regulatory requirements. You will identify common error areas that can be made into automated software logic to prevent overpayments from occurring. You will take edits from concept to specification and then through review, testing and finally data validation. Your goal is to develop claims editing logic and content that promote payment accuracy and transparency.

How You Will Make an Impact:

• Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
• Works with business partners to assist with cost of care claim editing goals.
• Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets.
• Review healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that can be turned into software editing rules.
• Create billing edits that provide clients with monetary savings and promote coding accuracy.
• Prepares and presents cost of care data analysis to support the regions cost of care initiatives.
• Develops and maintains the provider reimbursement strategy that will lower the cost of care, improve service, and reduce administrative expenses.
• Manages special projects and initiatives.

Minimum Requirements:

• Requires a BA/BS degree in a related field and a minimum of 7 years reimbursement experience including performing detailed financial modeling and economic analyses; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, & Experiences:

• 5+ years of claims editing experience with healthcare payers and/or claims editing software vendors, strongly preferred.
• Billing, coding, revenue cycle, and claims editing software experience.
• Nationally recognized coding or billing credentialrequired: CCS, CCS-P, CPC, CPB, CIC.
• Experience in claims adjudication and application of NCCI editing and claims payment rules.
• Ability to interpret claim edit rules and references.
• Solid understanding of claims workflow including the interconnection with claim forms
• Ability to apply industry coding guidelines to claim processes.
• Proven experience reviewing, analyzing, and researching coding issues for payment integrity.
• Logic skills: ability to break policy edits down into decision making paths.
• Ability to troubleshoot and apply root-cause analysis oflogicsnot functioning as intended.
• Intermediate levelproficiencyin Excel (ability to manipulate data using excel functions along with pivot tables, v-look up,etc.)
• Strong ideation skills.
• Inpatient coding skills highly preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.