Clinical Content & Reimbursement Director

Elevance Health • Indianapolis, IN

2d • $102,960 - $154,440 • Hybrid

About The Position

The Clinical Content & Reimbursement Director is responsible for driving the development and execution of the clinical content scope in alignment with the product and content strategy to meet financial and operational targets. This director will research and interpret CMS, CPT/AMA and other major payer policies based on medical coding and regulatory requirements. Identify common error areas that can be made into automated software logic to prevent overpayments from occurring. As well as take edits from concept to specification, through review, testing, and lastly data validation. With the goal to develop claims editing logic and content that promote payment accuracy and transparency.

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.

Nice To Haves

• Nationally recognized coding or billing credential (CCS, CCS-P, CPC, COC, CIC, CPB, RHIA, or RHIT) is strongly preferred.
• 10+ years of claims editing experience with healthcare payers and/or claims editing software vendors are strongly preferred.
• Commercial and Medicaid experience highly preferred.
• Inpatient and outpatient coding experience highly preferred.
• Strong knowledge of billing, coding, revenue cycle, claims adjudication, NCCI editing, and claims payment rules are highly preferred.
• Ability to interpret and apply claim edit rules, industry coding guidelines, and claims workflow processes preferred.
• Proven experience researching, analyzing, and resolving coding and payment integrity issues are preferred.
• Strong analytical and logic skills, including root-cause analysis and translating policy edits into decision-making logic paths are preferred.
• Intermediate Excel skills, including pivot tables, VLOOKUPs, and data manipulation are functions strongly preferred.
• SQL query-building and data lookup skills are preferred.
• Master’s degree preferred.

Responsibilities

• Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
• Works with business partners to assist with cost of care claim editing goals.
• Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets.
• Review healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that can be turned into software editing rules.
• Create billing edits that provide clients with monetary savings and promote coding accuracy.
• Prepares and presents cost of care data analysis to support the regions cost of care initiatives.
• Develops and maintains the provider reimbursement strategy that will lower the cost of care, improve service, and reduce administrative expenses.
• Manages special projects and initiatives.

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: Director