Provider Reimbursement Manager

Anticipated End Date:

Position Title:

Provider Reimbursement Manager

Job Description:

LOCATION:

Virtual eligible - Eastern or Central time zone highly preferred. You should be within a reasonable proximity to an eligible office.

HOURS:

General business hours, Monday through Friday.

Virtual:
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.

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. Alternate locations may be considered if candidates reside within a commuting distance from an office.

• Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
• Works with the Health Service Area, actuarial, decision support, and underwriting to ensure that accurate cost of care targets are incorporated into product pricing and the company's financial plans.
• Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets.
• Provides analytical support for hospital and physician negotiations.
• Prepares and presents cost of care data analysis to support the regions cost of care initiatives.
• Develops and maintains the provider reimbursement strategy that will lower the cost of care, improve service, and reduce administrative expenses.
• Manages special projects and initiatives.

Requires a BA/BS degree in a related field and a minimum of 7 years reimbursement experience including performing detailed financial modeling and economic analyses; or any combination of education and experience, which would provide an equivalent background.

• You must be CPC or CIC certified to be considered for this position.
• WGS and/or GBD Facets experience preferred.
• Experience working post-pay reviews, validation, and recovery processes in the healthcare industry strong preferred.
• Experience managing multiple projects in various stages to completion strongly preferred.
• Claim processing and adjustment experience strongly preferred.
• You should be comfortable speaking to external stakeholders to present concepts, and be an SME on CoC.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: PND >
Pricing Configuration

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.

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.

• Merit increases
• Paid holidays
• Paid Time Off
• 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
• Financial education resources

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…