Clinical Documentation and Claims Integrity Director
Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
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.
CareBridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. CareBridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services.
The Clinical Documentation and Claims Integrity Director will lead CareBridge's efforts in diagnostic documentation and claims integrity. This leader brings proven experience in payer and provider risk adjustment initiatives and possesses a deep understanding of end-to-end claims and encounter processing (including both fee-for-service and "zero-dollar" models). The ideal candidate may have also successfully scaled similar operations at a start-up-such as a value-based care provider or a healthcare services enablement company-and is well-versed in Medicare and Medicaid risk adjustment policies, RADV auditing, and the infrastructure that underpins claims delivery.
How you will make an impact:
Refine and build new infrastructure for end-to-end claims integrity, including associated reporting and KPIs.
Oversees design and execution of provider /chart review workflows to ensure high quality encounter submissions and disease documentation.
Liaises with senior CareBridge and Elevance Health leadership across Product, Analytics, and Clinical Operations teams.
Advises on vendor investments and operational best practices to support optimal encounter submissions and diagnostic documentation.
Minimum Requirements:
Requires BA/BS and a minimum of 5 years of related experience, including 3 years of hands-on HCC coding, chart review, and RAF calculations; or any combination of education and experience which would provide an equivalent background. Requires experience using RADV protocols and following Center for Medicare and Medicaid Services (CMS) and Affordable Care Act (ACA) rules.
Preferred Skills, Capabilities, and Experience:
Experience working with encounter data systems within a healthcare payer or RCM organization and associated coding/ claim integrity certifications strongly preferred.
Experience working with Medicare/ Medicaid and associated claims return files strongly preferred.
Preferred qualifications include an MPH, MHA, MBA, or MSN, or alternatively, training or certifications in health information technology.
Process improvement certification such as Six Sigma strongly preferred.
Experience in synthesizing large data sets/ interpreting KPIs to inform clinical and operational improvement strongly preferred.
Experience engaging with senior leadership strongly preferred.
Excellent written, oral, presentation and interpersonal communication skills with the proven ability to negotiate preferred.
Proficient of Microsoft Office products, most notably in PowerPoint, Teams, Outlook, Excel, and Word, strongly 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.
