Provider Reimbursement Manager

Anticipated End Date:

Position Title:

Job Description:

Location: Louisville KY Indianapolis IN Richmond VA Atlanta GA Mason OH Woodland Hills CA Grand Prairie TX New York NY

Hours: Standard Working hours

Travel: 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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 accommodation is granted as required by law.

Position Overview:

Manages key components of the provider reimbursement strategy. Serves as the primary point of contact for assigned Medicaid markets building strong working relationships with market leaders and operational teams to drive alignment on prepay editing strategy.

How You Will Make an Impact:

• Lead ongoing collaboration with markets to ensure prepay edit compliance with evolving state Medicaid guidelines translating regulatory changes into actionable edit requirements

• Identify and drive opportunities to improve cost of care performance including socializing new edit concepts quantifying impact and partnering with markets to remediate risk and implement changes

• Support onboarding of new Medicaid markets by conducting deep reviews of state-specific reimbursement rules billing guidelines and regulatory requirements and translating them into prepay edit logic

• Maintain and continuously enhance a centralized repository of state-specific edit requirements ensuring accuracy traceability and accessibility for stakeholders

• Act as a subject matter expert on prepay editing reimbursement policy and correct coding providing guidance to internal partners and influencing decision-making

• Partner cross-functionally with clinical coding analytics and technology teams to ensure edits are operationalized effectively and delivering expected outcomes

• Monitor performance and compliance across assigned markets proactively identifying gaps and driving corrective action

• Assigned Medicaid markets are consistently compliant with state-specific requirements and aligned to enterprise prepay edit strategy

• Demonstrated improvement in medical loss ratio (MLR) driven by effective edit implementation and cost-of-care initiatives

• New markets are onboarded efficiently with minimal rework and strong alignment to state guidelines from day one

• Clear well-maintained documentation of edit requirements that reduces ambiguity and accelerates implementation

Required Qualifications:

• 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 Qualifications:

• CPC RHIT or RHIA certifications preferred

• Deep working knowledge of prepay editing within Elevance including existing edit logic workflows and systems

• Strong understanding of correct coding initiatives (CCI) reimbursement policy and claims editing best practices

• Direct experience interpreting and operationalizing state Medicaid guidelines including translating regulatory language into actionable business rules

• Proven experience onboarding new Medicaid markets including assessing state-specific requirements and implementing compliant prepay edit strategies

• Experience maintaining ongoing market-level compliance through continuous monitoring gap identification and remediation

• Ability to influence without authority and drive alignment across market leadership operations and enterprise teams

• Strong analytical and problem-solving skills with the ability to connect regulatory requirements to financial and operational outcomes

For candidates working in person or virtually in the below location(s) the salary* range for this specific position is $80940 to $153360

Locations: California; New York

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 or any other form of compensation and benefits that are allocable to a particular employee

Job Level:

Workshift:

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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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13 the posting will automatically come down on 3/12 at 11:59:59 other words the job is posted until 3/13 not through 3/13.