Clinical Content & Editing Reimbursement Manager

Elevance Health • Indianapolis, IN

11d • $80,940 - $140,580 • Hybrid

About The Position

The Clinical Content & Editing Reimbursement Manager is responsible for managing the development and execution of clinical content and provider reimbursement strategies that support payment accuracy, regulatory compliance, and cost-of-care initiatives. This role partners with cross-functional teams to translate healthcare coding and reimbursement policies into clinical editing content and reimbursement solutions that improve financial performance, reduce administrative expenses, and enhance claims payment integrity across Commercial, Medicare, and Medicaid lines of business.

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.

Nice To Haves

• 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.

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.
• Partners 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.

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level