The Provider Reimbursement Administrator Senior ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria/configuration. Serves as subject matter expert regarding reimbursement policies, edits, and coding conventions.
How you will make an impact:
- Reviews company specific, CMS specific, and State specific medical policies, reimbursement policies, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
- Translates medical policies into reimbursement rule. Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
- Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
- Performs pre-adjudication claims reviews to ensure proper coding was used.
- Works with enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.
- Works with other departments on claims adjudication workflow development and business process improvements.
- May lead the full range of provider reimbursement activities for a state(s).
- Leads projects related to provider reimbursement initiatives.
- Serves as a mentor to less experienced administrators.
- Ensures compliance is being maintained by adhering to SOX controls, State mandates, CMS guidelines, and the Provider contract.
- Works with provider contracting staff when new/modified reimbursement contracts are needed.
- Coordinates research and responds to system inquires and appeals
- Requires a BA/BS degree; 4-6 years related experience; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Capabilities, and Experience:
- Medical billing and coding certification
- Claims processing
- Pricing Configuration in NetworX Pricer
- MS Office: Excel, Word, and some MS Access
- Rate Manager Experience including configuration of custom records
- Experience with CMS Guidelines
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. A Fortune 20 company with a longstanding history in the healthcare industry, 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 in certain patient/member-facing roles 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 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. 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 email@example.com for assistance.