Provider Reimburse Admin

Elevance Health • Chicago, IL

19h • Remote

About The Position

Provider Reimburse Admin Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Provider Reimburse Admin will be responsible for accurate translation of provider contracts, medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. How you will make an impact: Ensures accurate adjudication of claims, by translating provider contracts, medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy. Translates provider contracts into reimbursement and operational support rules. Coordinates research and responds to system inquiries. Conducts research of audit systems and system edits to identify claims audit rule inventory for accuracy. Trains staff on system issues and rule creations. Works with provider contracting staff when new/modified reimbursement contracts are needed.

Requirements

• Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

• Knowledge of provider networks, the medical management process, internal business processes, and expertise with internal local technology preferred.

Responsibilities

• Ensures accurate adjudication of claims, by translating provider contracts, medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.
• Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
• Translates provider contracts into reimbursement and operational support rules.
• Coordinates research and responds to system inquiries.
• Conducts research of audit systems and system edits to identify claims audit rule inventory for accuracy.
• Trains staff on system issues and rule creations.
• Works with provider contracting staff when new/modified reimbursement contracts are needed.

Benefits

• 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).

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees