Clinical Content & Editing Reimbursement Manager

Clinical Content & Editing Reimbursement Manager Hybrid work requires employees to be in office 1–2 days per week. Alternate locations may be considered if the candidate is within a reasonable commuting distance. Please note that candidates not within a reasonable commuting distance will not be considered unless an accommodation is granted. The Clinical Content & Editing Reimbursement Manager is responsible for managing the development and execution of clinical content and provider reimbursement strategies that support payment accuracy, regulatory compliance, and cost‑of‑care initiatives. The role partners with cross‑functional teams to translate healthcare coding and reimbursement policies into clinical editing content and reimbursement solutions that improve financial performance, reduce administrative expenses, and enhance claims payment integrity across Commercial, Medicare, and Medicaid lines of business. Responsibilities Lead development for specific plans and the implementation and ongoing optimization of clinical editing rules that support payment integrity and reimbursement accuracy. Partner with clinical content teams to ensure reimbursement strategies and initiatives support accurate cost‑of‑care targets and organizational financial objectives. Perform and direct complex fee modeling exercises and reimbursement analyses to ensure projected unit reimbursement changes meet corporate cost targets while aligning with regulatory and payment integrity requirements. Prepare and present reimbursement, coding, payment integrity, and cost‑of‑care analyses to support enterprise reimbursement and clinical editing initiatives. Develop and maintain provider reimbursement strategies and clinical content that promote payment accuracy, reduce overpayments, improve operational efficiency, and minimize administrative expenses. Research and interpret CMS regulations, CPT/AMA guidance, NCCI edits, Medicare and Medicaid payment policies, OIG guidance, and other industry references to support reimbursement methodologies and clinical editing content. Collaborate with Clinical Content, Engineering, Product, and Data teams to translate reimbursement and coding policies into functional editing specifications, validate editing logic, and ensure accurate implementation. Oversee validation activities to confirm reimbursement methodologies and clinical editing logic perform as intended through data analysis, testing, and root‑cause investigation. Manage special projects, strategic reimbursement initiatives, and continuous improvement efforts supporting payment integrity, reimbursement optimization, and clinical content development. Minimum Requirements BA/BS degree in a related field. Minimum of 7 years reimbursement experience, including detailed financial modeling and economic analyses. Alternatively, a combination of education and experience that provides equivalent background. Preferred Skills, Capabilities, & Experiences 5+ years of claims editing, payment integrity, provider reimbursement, clinical content development, or healthcare payer experience with health plans and/or claims editing software vendors. Nationally recognized coding or billing credential (CCS, CCS‑P, CPC, CPB, or CIC) with knowledge of CPT, HCPCS, ICD‑10‑CM/PCS, CMS regulations, NCCI, Medicare, Medicaid, and commercial payer reimbursement policies. Proven experience interpreting healthcare policies and translating coding and reimbursement guidelines into automated claims editing logic, functional specifications, and payment integrity solutions that improve claims accuracy and prevent overpayments. Strong analytical, problem‑solving, and root‑cause analysis skills with experience validating claims editing logic, researching complex coding and reimbursement issues, and collaborating across Product, Engineering, and Clinical Content teams. Intermediate proficiency with Microsoft Excel (PivotTables, VLOOKUP/XLOOKUP, and data analysis), SQL query and data validation experience supporting reimbursement analysis and payment integrity initiatives. Demonstrated ability to lead cross‑functional initiatives, communicate technical concepts to business stakeholders, manage multiple priorities, and deliver strategic reimbursement and clinical content solutions. Scaled Agile Framework (SAFe) experience preferred. Salary and Location Salary range: $80,940 to $140,580. Locations: Columbus, OH; Illinois; Virginia. Equal Employment Opportunity Statement Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact View email address on click.appcast.io for assistance. #J-18808-Ljbffr Elevance Health