Provider Reimbursement Manager

Elevance Health•St. Louis, MO

9d•Remote

About The Position

The Provider Reimbursement Manager manages key components of the provider reimbursement strategy. Primary duties may include, but are not limited to: Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules. Works with the Health Service Area, actuarial, decision support, and underwriting to ensure that accurate cost of care targets are incorporated into product pricing and the company's financial plans. Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets. Provides analytical support for hospital and physician negotiations. 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.

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

You must be CPC or CIC certified to be considered for this position.
WGS and/or GBD Facets experience preferred.
Experience working post-pay reviews, validation, and recovery processes in the healthcare industry strong preferred.
Experience managing multiple projects in various stages to completion strongly preferred.
Claim processing and adjustment experience strongly preferred.
You should be comfortable speaking to external stakeholders to present concepts, and be an SME on CoC.

Responsibilities

Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
Works with the Health Service Area, actuarial, decision support, and underwriting to ensure that accurate cost of care targets are incorporated into product pricing and the company's financial plans.
Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets.
Provides analytical support for hospital and physician negotiations.
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.