Provider Reimburse Director - Payment Integrity Strategy & Planning

Elevance Health • Wallingford, CT

16d • Hybrid

About The Position

Provider Reimburse Director - Payment Integrity Strategy & Planning Location: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/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 Director leads key provider reimbursement functions and initiatives across the enterprise and serves as subject matter expert regarding provider reimbursement strategies and practices. How you will make an impact: Leads the development and implementation of enterprise-wide provider reimbursement strategies, processes and systems for a major provider type, such as facilities. Works to drive the adoption and use of standardized reimbursement and contracting methodologies across the enterprise. Works with medical directors, contract negotiators, cost of care staff and provider relations staff to identify and implement best practice solutions to manage costs and reimburse for services. Facilitates the communication of activities, emerging trends, and best practices across all units and facilitates implementation of initiatives, through use of a steering committee containing representatives from the company's plans, regions, and business units. Researches and quantifies the impact of changes to reimbursement methodologies. May lead fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules. Manages special projects and initiatives. Represents the department and serves as a key contributor on enterprise initiatives, projects, and task forces. Oversees the gathering, documenting, and approving of policy-based implementation requirements. Establishes standardized processes for policy edit requirements team and assures adherence to processes.

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

• MBA or BA/BS degree in Business, Finance, Economics, or Healthcare Administration is highly preferred.
• Experience in broad-based, analytically oriented, managed care payor or provider environment is strongly preferred.
• Deep expertise in PI pre-pay editing, implementing requirements, and managing regular edit deployments strongly preferred.
• Strong understanding of claims and claims processing preferred.
• Knowledge and experience in the products and services of the respective industry strongly preferred.
• Experience and knowledge of process improvement and change management experience (strategic and execution) strongly preferred.
• Experience interacting confidently with senior management and executive level stakeholders, as a subject matter expert and comfortable with influencing decision-making preferred.
• Excellent written, oral, presentation and interpersonal communication skills with the proven ability to negotiate expectations between multiple parties strongly preferred.

Responsibilities

• Leads the development and implementation of enterprise-wide provider reimbursement strategies, processes and systems for a major provider type, such as facilities.
• Works to drive the adoption and use of standardized reimbursement and contracting methodologies across the enterprise.
• Works with medical directors, contract negotiators, cost of care staff and provider relations staff to identify and implement best practice solutions to manage costs and reimburse for services.
• Facilitates the communication of activities, emerging trends, and best practices across all units and facilitates implementation of initiatives, through use of a steering committee containing representatives from the company's plans, regions, and business units.
• Researches and quantifies the impact of changes to reimbursement methodologies.
• May lead fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
• Manages special projects and initiatives.
• Represents the department and serves as a key contributor on enterprise initiatives, projects, and task forces.
• Oversees the gathering, documenting, and approving of policy-based implementation requirements.
• Establishes standardized processes for policy edit requirements team and assures adherence to processes.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

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