Senior Advisor – Rx Claims & Adjudication (Business Architect)

Elevance Health•Atlanta, OH

19d•Hybrid

About The Position

The Senior Advisor – Rx Claims & Adjudication ( Business Architect) will be responsible for driving and completing the Business Architecture portion of business blueprints, including establishing guiding principles, defining capabilities, performing functional analysis/definition, analyzing and documenting the value chain, and assessing organizational impacts. This role requires associates to be in-office 1 - 2 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. 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. This position is not eligible for current or future visa sponsorship.

Requirements

Requires an BA/BS degree in Information Technology, Computer Science or related field of study and a minimum of 5 years of experience in business analyst and strategic planning, IT operations, IT leadership strategic and technical architecture with a minimum of 3 years in organizational management as it related to information architecture; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Deep claims adjudication expertise
Pricing methodologies (AWP, MAC, GER, rebates)
NCPDP standards and claim transactions
Understanding of PBM operations payer workflows and Claims adjudication platforms
Strategic advisory capability
Present confidently to leadership and external stakeholders
Ability to bridge business + technical discussions effectively

Responsibilities

Serve as the enterprise Subject Matter Expert (SME) on pharmacy claims adjudication, benefit design, and pricing logic.
Interpret complex adjudication outcomes and translate into clear business decisions.
Identify adjudication defects, inconsistencies, and financial leakage risks.
Support resolution of high-impact claims issues and escalations.
Advise on claims platform configuration (e.g., rules, pricing logic, edits).
Represent the organization in client discussions, audits, and SME panels.
Participates in providing linkage to other Enterprise Architecture groups and models, and coordinate and align activities to achieve the future state capabilities in partnership with Business Relationship Management (BRM).
Contributes to Reference architectures, Strategic Business Architecture (SBA) and Operational Business Architecture (OBA) that articulate a future state direction to optimize the value chain.
Contributes to Business Architecture portion of business blueprints, including establishing guiding principles, defining capabilities, performing functional analysis/definition, analyzing and documenting the value chain, and assessing organizational impacts.
Proposes ideas for performing enterprise wide functional analysis to identify areas for efficiencies or rationalization opportunities, and conduct ongoing analysis of business capabilities and how improvements to architecture components can best support capabilities.
Executes a common process for how projects are assessed against business architecture artifacts and blueprints; incorporate into overall architecture governance process.
Communicates and builds consensus equally effectively with more than one constituents, including business executives, technologists, end users, and operations.