Provider Reimbursement & Prepay Editing Director

Overview

Carelon, a proud member of the Elevance Health family of companies, is seeking a Provider Reimbursement & Prepay Editing Director to lead key provider reimbursement and prepay editing functions and initiatives across the enterprise.

Responsibilities

• 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.

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 include 8–12+ years of experience in provider reimbursement, payment integrity, claims editing, reimbursement policy implementation, or prepay editing operations; strong knowledge of prepay editing methodologies, reimbursement policy interpretation, and claims editing governance; experience supporting reimbursement edit implementation, maintenance, defect management, and operational quality initiatives; professional coding certification such as CPC, CCS, RHIT, or equivalent coding certification or experience; strong understanding of reimbursement methodologies, medical coding principles, and payment integrity operations; experience working within complex matrixed healthcare organizations and leading cross-functional initiatives without direct authority; experience supporting audit, regulatory, and compliance activities related to provider reimbursement and claims editing operations; strong communication, analytical, problem-solving, and stakeholder management skills.

Benefits

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 Opportunity Employer

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.