Carelon Payment Integrity Manager - Kansas

Elevance Health•Topeka, KS

2d•Hybrid

About The Position

The Carelon Payment Integrity Manager – Kansas 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.

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.

Nice To Haves

2-5 years of experience with Fraud, Waste and Abuse.
Experience with payment integrity.
Familiarity with claims systems and processes.
Experience with GBD Facets.

Responsibilities

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 regulatory compliance and Health Care Reform changes to determine potential impact.
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 corrective 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.