Audit & Reimbursement Lead - Appeals

Audit & Reimbursement Lead - Appeals

Audit and Reimbursement Lead - Appeals

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. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

The Audit & Reimbursement Lead - Appeals is responsible for providing technical direction, workload planning, associate mentoring and operational support on a day-to-day basis.

How you will make an impact:

• Reviews work of the associates to ensure they are following the appropriate guidelines, provides training both in a formal and informal setting, reviews the policies and procedures to make sure they are appropriate, and monitors workload inventory to ensure timely completion. Handles complex case research and resolutions.
• Will support the Appeal Unit with appeal issues as assigned. Participates in special projects and review of work done by lower level auditors.
• Analyzes and interprets data and makes recommendations for change based on their judgment and experience. Able to work independently on assignments and under minimal guidance from the manager.
• Monitors inventory to ensure workflow remains uninterrupted.
• Assists management with workload and financial budget responsibilities.
• Must have extensive knowledge of CMS principles, law and regulations.
• Works with management on interaction with internal and external audits and performance measures. Assists in ISO and NASBA certification activities.
• Associates in this role are expected to maintain continuing education requirements.

Minimum Requirements:

• Requires a BA/BS degree and a minimum of 8 years audit/reimbursement or related Medicare experience which includes previous experience at a Senior Auditor level in health care, public accounting or a government agency; or any combination of education and experience, which would provide an equivalent background.
• This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States for at least three of the past five years.

Preferred Skills, Capabilities, and Experiences:

• Accounting degree preferred. Experience in software used to file and finalize cost reports and experience with paperless audit software applications preferred.
• Demonstrated leadership experience; through knowledge of CMS program regulations and cost report format preferred.
• Knowledge of CMS computer systems and Microsoft Office Word and Excel strongly preferred.
• MBA, CPA, CIA or CFE preferred.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed."

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $87,120 - $137,214

Locations: Maryland; Massachusetts; New York

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). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.