Provider Reimbursement Admin Sr

Provider Reimbursement Admin Sr Location : 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. 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. This position is not eligible for employment based sponsorship. The Provider Reimbursement Admin Sr is responsible for ensuring accurate adjudication of claims, translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. This role also leverages data analysis, problem-solving techniques, and emerging AI-driven tools to enhance reimbursement accuracy and efficiency. Serves as a subject matter expert regarding reimbursement policies, edits, and coding conventions, while supporting data-informed decision-making. How you will make an impact Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates. Apply analytical and problem-solving skills to evaluate claims data, identify cost-of-care improvement opportunities, and support business decision-making. Performs data analysis to assess reimbursement strategies and recommend improvements. Utilizes AI-enabled tools and advanced analytics to identify trends, optimize claims adjudication processes, and improve accuracy and efficiency. Works with other departments on claims adjudication workflow development and business process improvements. May lead the full range of provider reimbursement activities for a state(s), incorporating data-driven insights into strategy. Leads projects related to provider reimbursement initiatives. Minimum Requirements Requires a BA/BS degree and a minimum of 4 years related experience; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities and Experience Medical billing and coding certification strongly preferred. Certified Professional Coder (CPC) strongly preferred. Knowledge of fee schedule development and maintenance processes, including quarterly updates, is strongly preferred. Strong analytical, critical thinking, and problem-solving skills with experience in healthcare data analysis strongly preferred. Experience with AI tools, predictive modeling, or advanced analytics applied to claims or cost-of-care initiatives preferred. Ability to interpret complex data sets and translate insights into actionable business recommendations is strongly preferred. The salary range for this position is $81,420 to $122,130. Located in California. In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401(k) contribution (all benefits are subject to eligibility requirements). 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