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Provider Reimbursement Administrator - Carelon Payment Integrity

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  • Job
    Full-time
    Junior (1-2 years)
  • Atlanta

Requirements

  • 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

Responsibilities

  • - 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.

FAQs

Do we support remote work?

Yes, we support remote work in a hybrid format, requiring 1-2 days per week in the office.

What is the main responsibility of the Provider Reimbursement Administrator?

The main responsibility is to ensure accurate adjudication of claims by translating medical policies, reimbursement policies, and clinical editing policies into effective reimbursement criteria.

What are the minimum educational requirements for this position?

A BA/BS degree and a minimum of 2 years of related experience are required, or a combination of education and experience that provides an equivalent background.

Is a coding certification preferred for this role?

Yes, a coding certification is preferred for the Provider Reimbursement Administrator position.

What skills are highly desired for candidates applying for this position?

Proficiency in Excel and analytics, as well as the ability to manipulate data files, are highly desired skills.

What are the preferred qualifications for this position?

A registered nurse with an active license is strongly preferred.

What will the Provider Reimbursement Administrator do regarding claims reviews?

The administrator will perform pre-adjudication claims reviews to ensure proper coding was used, as well as conduct research of claims systems to identify adjudication issues.

What locations are eligible for this position?

Eligible locations include District of Columbia (Washington, DC) and New York.

What is the salary range for this position?

The salary range for this position is $57,456 to $98,496.

Are there benefits offered with this position?

Yes, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contributions, all subject to eligibility requirements.

Improving the health of humanity

Science & Healthcare
Industry
10,001+
Employees

Mission & Purpose

Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner.   Our nearly 100,000 associates serve more than 118 million people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health.  We believe that improving health for everyone is possible. It begins by redefining health, reimagining the health system, and strengthening our communities.

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