Clinical Content & Editing Reimbursement Manager

About the role

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.

Responsibilities

• Leads development for specific plan(s) and/or the development, implementation, and ongoing optimization of clinical editing rules that support payment integrity and reimbursement accuracy.
• Pairs with the clinical content teams to ensure reimbursement strategies and clinical editing initiatives support accurate cost-of-care targets and organizational financial objectives.
• Performs and/or directs complex fee modeling exercises and reimbursement analyses to ensure projected unit reimbursement changes meet corporate cost targets while aligning with regulatory and payment integrity requirements.
• Prepares and presents reimbursement, coding, payment integrity, and cost-of-care analyses to support enterprise reimbursement and clinical editing initiatives.
• Develops and maintains provider reimbursement strategies and clinical content that promote payment accuracy, reduce overpayments, improve operational efficiency, and minimize administrative expenses.
• Researches and interprets CMS regulations, CPT/AMA guidance, NCCI edits, Medicare and Medicaid payment policies, OIG guidance, and other industry references to support reimbursement methodologies and clinical editing content.
• Collaborates with Clinical Content, Engineering, Product, and Data teams to translate reimbursement and coding policies into functional editing specifications, validate editing logic, and ensure accurate implementation.
• Oversees validation activities to confirm reimbursement methodologies and clinical editing logic perform as intended through data analysis, testing, and root-cause investigation.
• Manages special projects, strategic reimbursement initiatives, and continuous improvement efforts supporting payment integrity, reimbursement optimization, and clinical content development.

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, payment integrity, provider reimbursement, clinical content development, or healthcare payer experience with health plans and/or claims editing software vendors, including expertise in billing, coding, revenue cycle, and claims adjudication preferred.
• Nationally recognized coding or billing credential (CCS, CCS-P, CPC, CPB, or CIC) with demonstrated knowledge of CPT, HCPCS, ICD-10-CM/PCS, CMS regulations, National Correct Coding Initiative (NCCI), Medicare, Medicaid, and commercial payer reimbursement policies preferred.
• Proven experience interpreting healthcare policies and translating coding and reimbursement guidelines into automated claims editing logic, functional specifications, and payment integrity solutions that improve claims accuracy and prevent overpayments preferred.
• Strong analytical, problem-solving, and root-cause analysis skills with experience validating claims editing logic, researching complex coding and reimbursement issues, and collaborating with Product, Engineering, and Clinical Content teams throughout development and implementation preferred.
• Intermediate proficiency with Microsoft Excel (including PivotTables, VLOOKUP/XLOOKUP, and data analysis), with SQL query and data validation experience supporting reimbursement analysis and payment integrity initiatives preferred.
• Demonstrated ability to lead cross-functional initiatives, communicate technical concepts to business stakeholders, manage multiple priorities, and deliver strategic reimbursement and clinical content solutions preferred.
• Scaled Agile Framework (SAFe) experience preferred.

Benefits

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.

Equal Employment Opportunity

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.