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Provider Reimbursement & Prepay Editing Director

Hybrid 2: This role requires associates to be in-office 3 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.

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center-connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together.
Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health.

The Provider Reimbursement & Prepay Editing Director is responsible for leading key provider reimbursement and prepay editing functions and initiatives across the enterprise and serves as subject matter expert regarding provider reimbursement strategies, reimbursement policy implementation, and claims editing practices.

How You Will Make an Impact

Primary duties may include, but are not limited to:

• Leads the development and implementation of enterprise-wide provider reimbursement strategies, processes, systems, and prepay editing initiatives for a major provider type, such as facilities.

• Works to drive the adoption and use of standardized reimbursement, claims editing, and reimbursement policy methodologies across the enterprise.

• Works with medical directors, contract negotiators, coding teams, cost of care staff, payment integrity partners, and provider relations staff to identify and implement best practice solutions to manage costs and reimburse services appropriately.

• Facilitates the communication of activities, emerging trends, reimbursement policy updates, and best practices across all units and facilitates implementation of initiatives through use of a steering committee containing representatives from the company's plans, regions, and business units.

• Researches and quantifies the impact of changes to reimbursement methodologies, reimbursement policies, and claims editing initiatives.

• May lead fee schedule development for specific plan(s) and/or the development, implementation, and oversight of clinical editing rules and reimbursement edit governance activities.

• Supports operational quality improvement initiatives, including defect management, issue resolution, and root cause analysis related to claims editing and reimbursement activities.

• Manages special projects and initiatives related to provider reimbursement, payment integrity, and prepay editing operations.

• Represents the department and serves as a key contributor on enterprise initiatives, projects, audit activities, and task forces.

Minimum Requirements:

Requires a BS/BA degree in a related field and a minimum of 10 years business and professional experience in provider reimbursement and contracting, provider relations, and provider servicing; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, & Experiences:

• 8-12+ years of experience in provider reimbursement, payment integrity, claims editing, reimbursement policy implementation, or prepay editing operations preferred.

• Strong knowledge of prepay editing methodologies, reimbursement policy interpretation, and claims editing governance preferred.

• Experience supporting reimbursement edit implementation, maintenance, defect management, and operational quality initiatives preferred.

• Professional coding certification such as CPC, CCS, RHIT, or equivalent coding certification or experience preferred.

• Strong understanding of reimbursement methodologies, medical coding principles, and payment integrity operations preferred.

• Experience working within complex matrixed healthcare organizations and leading cross-functional initiatives without direct authority preferred.

• Experience supporting audit, regulatory, and compliance activities related to provider reimbursement and claims editing operations preferred.

• Strong communication, analytical, problem-solving, and stakeholder management skills 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.