Carelon Integrity Manager - Kansas

Carelon Payment Integrity Manager - Kansas

Location: Kansas

Hybrid: 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. 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.

The Carelon Payment Integrity Manager – Kansas is responsible for ensuring the accuracy of claims payment through the management of a robust process for prevention, detection, and correction of billing, payment and membership errors. Works with health plan leaders, oversees the monitoring and enforcement of the fraud, waste, and abuse compliance program to prevent and detect potential fraud, waste, and abuse activities pursuant to state and federal rules and regulations.

• Coordinate and respond to inquiries from executives, ensuring timely and accurate communication.
• Handle the processing and management of Payment Integrity waivers.
• Assist in preparing responses to Requests for Proposals across all lines of business.
• Document process flows accurately to ensure clear and effective communication of processes.
• Help with preparing presentations, ensuring they are polished and ready for delivery.
• Review and approve performance guarantees, ensuring compliance with standards.
• Has detailed technical knowledge of claims payment accuracy and participates on cross functional teams focused on problem remediation and long-term resolution.
• Anticipates the effect of changes in the business environment on future claim errors.
• Evaluates regulatory compliance and Health Care Reform changes to determine potential impact.
• Evaluates provider activities to assist in the detection of fraud, waste and abuse activities.
• Monitors provisions of the compliance plan, including fraud, waste, and abuse policies and procedures, investigates unusual incidents and implements corrective action plans.
• Develops and analyzes monthly reports.
• Develops project plans and oversees project execution, issue management and progress reporting.
• Develops processes to support early detection of systemic issues causing operational inefficiencies.

• Requires a BA/BS in business, engineering, nursing, finance, or healthcare administration and minimum of 5 years related work experience, including minimum of 2 years leadership experience; or any combination of education and experience, which would provide an equivalent background.

• 2-5 years of experience with Fraud, Waste and Abuse.
• Experience with payment integrity.
• Familiarity with claims systems and processes.
• Experience with GBD Facets.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and 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 and financial education resources, to name a few.

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 become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state, and local laws.

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 elevancehealthj for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should…