Audit & Reimbursement Lead- Appeals

Audit & Reimbursement Lead

_Location: _ 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.

*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.

Wellpoint Federal is a proud member of Elevance Health’s family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

The Audit and Reimbursement Lead will support our Medicare Administrative Contract (MAC) with the federal government (The Centers for Medicare and Medicaid Services (CMS) division within the Department of Health and Human Services). Under direction of management, the Audit and Reimbursement Lead will provide technical leadership, supervision and coordination on contractual workload involving the Medicare cost report and Medicare Part A reimbursement. This position provides a valuable opportunity to lead team members performing auditing and financial analysis within a growing healthcare industry. This position allows for educational opportunities leading to certifications and promotes a well-balanced lifestyle that includes professional networking opportunities. 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/mentoring both in a formal and informal setting.

• Monitors workload inventory to ensure timely completion.

• Handles complex case research and resolutions.

• 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

• Assist management on monitoring and training lower-level staff.

• Analyze and interpret data with recommendations based on judgment and experience.

• Must be able to perform all duties of lower-level positions as directed by management.

• Participate in development and maintenance of Audit & Reimbursement standard operating procedures.

• Participate in workgroup initiatives to enhance quality, efficiency and training.

• Participate on special projects as needed.

• Perform supervisory review on cost report appeals – position papers, jurisdiction reviews, work papers, Administrative Resolutions, and other work.

• Perform supervisory review of cost report reopenings.

• Perform supervisory review on complex areas of the Medicare cost report such as Medicare DSH, Bad Debts, IME/DGME, NAH, Organ Acquisition, Wage Index and all cost-based principles.

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 meet the residency requirement of living in the United States 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.

• Must obtain Continuing Education Training requirements (where required).

• A valid driver's license and the ability to travel may be required.

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.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration ( .