Provider Reimburse Admin Sr

Provider Reimburse Admin Sr

Location : Norfolk VA, Richmond VA, Wallingford CT, Durham NC, Atlanta GA, Indianapolis IN, Mason OH, Grand Prairie TX Hours : Monday - Friday Travel : 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.

Position Overview : Provider Reimburse Admin Sr ensures accurate adjudication of claims by translating provider contracts, reimbursement policies, CMS guidelines, and medical policies into effective and accurate reimbursement configuration in FACETS NetworX.

How You Will Make an Impact :

• Reviewing provider contracts to ensure compliance is being maintained by adhering to SOX controls, State mandates, and CMS guidelines.
• Analyzing new provider contracts for coverage, policy, reimbursement development, and implications for system edits.
• Configuring complex pricing and new reimbursement methodologies for physician, facility, and ancillary contracts.
• Configuring, maintaining, and troubleshooting DOFR tables within Facets to ensure accurate financial responsibility across PCPs, IPAs, and delegated entities.
• Responding to system inquiries and appeals primarily in order to troubleshoot claims adjudication issues related to configuration.
• Creating test claims and performing reviews of claims to ensure proper configuration.
• Conducting research of claims and system edits to identify issues.
• Leading projects related to provider reimbursement and automation initiatives.
• Serving as a mentor to less experienced administrators.
• Working with other departments to resolve system issues.
• Working with provider contracting staff regarding new and / or modified reimbursement contracts.
• Assisting with the analysis, documentation, configuration, and testing of current and future markets business requirements.
• Supporting the upgrade of test environments.

Required Qualifications : 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 Qualifications : Experience with FACETS NetworX configuration a MUST DOFR (division of financial responsibility) Table Configuration strongly preferred Claims and billing experience strongly preferred Physician and facility pricing configuration experience strongly preferred Experience running Microsoft Access queries in relation to FACETS tables (Microsoft Access, TOAD, Oracle) strongly preferred Experience with Rate Manager; including configuration of custom records preferred. Must know how to read and analyze a contract (physician, ancillary and hospital). Able to implement PCAs and load fee schedules. Able to use full range of Microsoft Office products proficiently Experience leading or taking a primary role in the configuration of enterprise-class information systems / software products in a highly regulated business environment preferred Medicaid and Medicare experience strongly preferred Knowledge of CPT / HCPCS coding preferred Experience working with the implementation of new business in a health insurance industry setting

Who We Are 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.

How We Work 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. 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 elevancehealthjobssupport@elevancehealth.com 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.