Provider Reimbursement Admin Sr

Location: Woodland Hills

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, by 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.

For candidates working in person or virtually in the below location, the salary
* range for this specific position is 81,420 to $122,130

Location:

California

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…