Job Description

Provider Reimbursement Administrator – Carelon Payment Integrity

Location : The ideal candidate will live within 50 miles of one of our pulse point locations and will work on a hybrid work model (1-2 days per week in the office).

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate, and prevent unnecessary medical-expense spending.

The Provider Reimbursement Administrator ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.

How you will make an impact:

Reviews company-specific, CMS-specific, and competitor-specific medical policies, reimbursement policies, and editing rules, as well as conducts clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.

Translates medical policies into reimbursement rules.

Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.

Coordinates research and responds to system inquiries and appeals. Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.

Performs pre-adjudication claims reviews to ensure proper coding was used.

Prepares correspondence to providers regarding coding and fee schedule updates.

Trains customer service staff on system issues.

Works with provider contracting staff when new/modified reimbursement contracts are needed.

Minimum Requirements:

Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background.Preferred Qualifications, Skills, and Experiences:

Registered Nurse with active licenses strongly preferred

Proficient in Excel and analytics highly desired

Ability to manipulate data files strongly desired

Coding certification preferred

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $57,456 to $98,496.

Locations: District of Columbia (Washington, DC), 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 .

The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.