Carelon Payment Integrity Manager
Carelon Payment Integrity Manager
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Job Description
Anticipated End Date:
Position Title:
Carelon Payment Integrity ManagerJob Description:
Carelon Payment Integrity Manager
Hybrid 1: 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.
Carelon Payment Integrity is a proud member of the Elevance Health family of companies Carelon Insights formerly Payment Integrity is determined to recover eliminate and prevent unnecessary medical-expense spending.
The Carelon Payment Integrity Manager is responsible for ensuring the accuracy of claims payment through the management of a robust process for prevention detection and correction of billing payment and membership errors. Works with health plan leaders oversees the monitoring and enforcement of the fraud waste and abuse compliance program to prevent and detect potential fraud waste and abuse activities pursuant to state and federal rules and regulations. This role involves providing both administrative and strategic support to the Payment Integrity Account Management team.
How you will make an impact:
- Coordinate and respond to inquiries from executives ensuring timely and accurate communication.
- Handle the processing and management of Payment Integrity waivers.
- Assist in preparing responses to Requests for Proposals across all lines of business.
- Document process flows accurately to ensure clear and effective communication of processes.
- Help with preparing presentations ensuring they are polished and ready for delivery.
- Review and approve performance guarantees ensuring compliance with standards.
- Has detailed technical knowledge of claims payment accuracy and participates on cross functional teams focused on problem remediation and long term resolution.
- Anticipates the effect of changes in the business environment on future claim errors.
- Evaluates provider activities to assist in the detection of fraud waste and abuse activities.
- Monitors provisions of the compliance plan including fraud waste and abuse policies and procedures investigates unusual incidents and implements corective action plans.
- Develops and analyzes monthly reports.
- Develops project plans and oversees project execution issue management and progress reporting.
- Develops processes to support early detection of systemic issues causing operational inefficiencies.
Minimum Requirements:
Requires a BA/BS in business engineering nursing finance or healthcare administration and minimum of 5 years related work experience including minimum of 2 years leadership experience; or any combination of education and experience which would provide and equivalent background.
Preferred Skills Capabilities and Experiences:
- Must have experience or strong knowledge in payment integrity.
- Familiarity with claims systems and processes with knowledge of systems like GBD Facets.
- Medicaid experience preferred.
Job Level:
Non-Management ExemptWorkshift:
1st Shift (United States of America)Job Family:
FRD > CompliancePlease 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 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.
Required Experience:
Manager
Employment Type
Full-Time
