Clinical Content & Reimbursement 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.
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 Clinical Content & Reimbursement Director 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.
This director will research and interpret CMS, CPT/AMA and other major payer policies based on medical coding and regulatory requirements. Identify common error areas that can be made into automated software logic to prevent overpayments from occurring. As well as take edits from concept to specification, through review, testing, and lastly data validation. With the goal to develop claims editing logic and content that promote payment accuracy and transparency.
How You Will Make an Impact
Primary duties may include, but are not limited to:
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 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:
Nationally recognized coding or billing credential (CCS, CCS-P, CPC, COC, CIC, CPB, RHIA, or RHIT) is strongly preferred.
10+ years of claims editing experience with healthcare payers and/or claims editing software vendors are strongly preferred.
Commercial and Medicaid experience highly preferred.
Inpatient and outpatient coding experience highly preferred.
Strong knowledge of billing, coding, revenue cycle, claims adjudication, NCCI editing, and claims payment rules are highly preferred.
Ability to interpret and apply claim edit rules, industry coding guidelines, and claims workflow processes preferred.
Proven experience researching, analyzing, and resolving coding and payment integrity issues are preferred.
Strong analytical and logic skills, including root-cause analysis and translating policy edits into decision-making logic paths are preferred.
Intermediate Excel skills, including pivot tables, VLOOKUPs, and data manipulation are functions strongly preferred.
SQL query-building and data lookup skills are preferred.
Master's degree preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $102,960.00 to $154,440.00.
Location: Columbus, OH.
In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .
*The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, paid time off, stock, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
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 (https://info.flclearinghouse.com/) .
