Manager, Clinical Content & Reimbursement

Elevance Health•Atlanta, VA

1d•Hybrid

About The Position

The Manager, Clinical Content & Reimbursement (Provider Reimbursement Manager) 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. You’ll research and interpret CMS, CPT/AMA and other major payer policies based on medical coding and regulatory requirements. You will identify common error areas that can be made into automated software logic to prevent overpayments from occurring. You will take edits from concept to specification and then through review, testing and finally data validation. Your goal is to develop claims editing logic and content that promote payment accuracy and transparency.

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 experience with healthcare payers and/or claims editing software vendors, strongly preferred.
Billing, coding, revenue cycle, and claims editing software experience.
Nationally recognized coding or billing credential : CCS, CCS-P, CPC, CPB , CIC.
Experience in claims adjudication and application of NCCI editing and claims payment rules.
Ability to interpret claim edit rules and references.
Solid understanding of claims workflow including the interconnection with claim forms
Ability to apply industry coding guidelines to claim processes.
Proven experience reviewing, analyzing, and researching coding issues for payment integrity.
Logic skills: ability to break policy edits down into decision making paths.
Ability to troubleshoot and apply root-cause analysis of logics not functioning as intended.
Intermediate level proficiency in Excel (ability to manipulate data using excel functions along with pivot tables, v-look up, etc. )
Strong ideation skills.
Inpatient coding skills highly 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.