Job Description
Job description
Supporting the Payment Integrity line of business
Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.
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.
• Coordinates research and responds to provider inquiries.
• 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 correct coding practices.
• Trains customer service staff on system issues.
• Works with provider contracting staff when new/modified reimbursement contracts are needed.
• Executes meticulous reviews of medical records to confirm whether the documentation justifies the level of service provided.
• Conducts strategic analyses of claims data to bolster the creation of educational concepts.
• Furnishes providers with comprehensive feedback on current year coding guidelines and industry expertise, facilitated through phone and email correspondences.
• Leverages extensive coding proficiency, clinical guidelines, and industry knowledge to validate conclusions.
• Upholds management-prescribed accuracy and quality protocols for concept definitions, identifying valid claims, and documentation purposes. This includes tasks such as letter compositions and spotting new claim types by pinpointing potential claims outside the given concept where there may be additional educational opportunities.
• Actively develops recommendations for enhancing concept definitions and improving process efficiency.
• Undertakes additional responsibilities as directed.
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 & Capabilities
• CPC certification preferred.
• Experience in health insurance reimbursement, medical billing, medical coding, auditing, or health data analytics preferred.
• Possesses powerful communication, analytical, and decision-making abilities, manages multiple demands efficiently, values cultural diversity, highly energized, and multitasks across various projects proactively.
• Proficiency with MS Outlook, Word and Excel preferred.
• Experience with MS Access preferred.
For candidates working in person or remotely in the below location(s), the salary range for this specific position is $62,+28 to $+8,4+6.
Locations: California; District of Columbia (Washington, DC).
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.
Supporting the Payment Integrity line of business
Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.
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.
• Coordinates research and responds to provider inquiries.
• 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 correct coding practices.
• Trains customer service staff on system issues.
• Works with provider contracting staff when new/modified reimbursement contracts are needed.
• Executes meticulous reviews of medical records to confirm whether the documentation justifies the level of service provided.
• Conducts strategic analyses of claims data to bolster the creation of educational concepts.
• Furnishes providers with comprehensive feedback on current year coding guidelines and industry expertise, facilitated through phone and email correspondences.
• Leverages extensive coding proficiency, clinical guidelines, and industry knowledge to validate conclusions.
• Upholds management-prescribed accuracy and quality protocols for concept definitions, identifying valid claims, and documentation purposes. This includes tasks such as letter compositions and spotting new claim types by pinpointing potential claims outside the given concept where there may be additional educational opportunities.
• Actively develops recommendations for enhancing concept definitions and improving process efficiency.
• Undertakes additional responsibilities as directed.
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 & Capabilities
• CPC certification preferred.
• Experience in health insurance reimbursement, medical billing, medical coding, auditing, or health data analytics preferred.
• Possesses powerful communication, analytical, and decision-making abilities, manages multiple demands efficiently, values cultural diversity, highly energized, and multitasks across various projects proactively.
• Proficiency with MS Outlook, Word and Excel preferred.
• Experience with MS Access preferred.
For candidates working in person or remotely in the below location(s), the salary range for this specific position is $62,+28 to $+8,4+6.
Locations: California; District of Columbia (Washington, DC).
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.
💡 Quick Summary
Seeking a career-building opportunity? The Provider Reimbursement Administrator position is now open for candidates interested in the Accountant Jobs sector. This role in West Des Moines offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Accountant Jobs is a plus.
