Clinical Content & Editing Reimbursement Manager

Anticipated End Date:

Position Title:

Job Description:

Clinical Content & Editing Reimbursement Manager

Hybrid 1: 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.

The Clinical Content & Editing Reimbursement Manager is responsible for managing the development and execution of clinical content and provider reimbursement strategies that support payment accuracy, regulatory compliance, and cost-of-care initiatives. This role partners with cross-functional teams to translate healthcare coding and reimbursement policies into clinical editing content and reimbursement solutions that improve financial performance, reduce administrative expenses, and enhance claims payment integrity across Commercial, Medicare, and Medicaid lines of business.

How You Will Make an Impact

Primary duties may include, but are not limited to:

• Leads development for specific plan(s) and/or the development, implementation, and ongoing optimization of clinical editing rules that support payment integrity and reimbursement accuracy.

• Partners with the clinical content teams to ensure reimbursement strategies and clinical editing initiatives support accurate cost-of-care targets and organizational financial objectives.

• Performs and/or directs complex fee modeling exercises and reimbursement analyses to ensure projected unit reimbursement changes meet corporate cost targets while aligning with regulatory and payment integrity requirements.

• Prepares and presents reimbursement, coding, payment integrity, and cost-of-care analyses to support enterprise reimbursement and clinical editing initiatives.

• Develops and maintains provider reimbursement strategies and clinical content that promote payment accuracy, reduce overpayments, improve operational efficiency, and minimize administrative expenses.

• Researches and interprets CMS regulations, CPT/AMA guidance, NCCI edits, Medicare and Medicaid payment policies, OIG guidance, and other industry references to support reimbursement methodologies and clinical editing content.

• Collaborates with Clinical Content, Engineering, Product, and Data teams to translate reimbursement and coding policies into functional editing specifications, validate editing logic, and ensure accurate implementation.

• Oversees validation activities to confirm reimbursement methodologies and clinical editing logic perform as intended through data analysis, testing, and root-cause investigation.

• Manages special projects, strategic reimbursement initiatives, and continuous improvement efforts supporting payment integrity, reimbursement optimization, and clinical content development.

Minimum Requirements:

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.

Preferred Skills, Capabilities, & Experiences:

• 5+ years of claims editing, payment integrity, provider reimbursement, clinical content development, or healthcare payer experience with health plans and/or claims editing software vendors, including expertise in billing, coding, revenue cycle, and claims adjudication preferred.

• Nationally recognized coding or billing credential (CCS, CCS-P, CPC, CPB, or CIC) with demonstrated knowledge of CPT, HCPCS, ICD-10-CM/PCS, CMS regulations, National Correct Coding Initiative (NCCI), Medicare, Medicaid, and commercial payer reimbursement policies preferred.

• Proven experience interpreting healthcare policies and translating coding and reimbursement guidelines into automated claims editing logic, functional specifications, and payment integrity solutions that improve claims accuracy and prevent overpayments preferred.

• Strong analytical, problem-solving, and root-cause analysis skills with experience validating claims editing logic, researching complex coding and reimbursement issues, and collaborating with Product, Engineering, and Clinical Content teams throughout development and implementation preferred.

• Intermediate proficiency with Microsoft Excel (including PivotTables, VLOOKUP/XLOOKUP, and data analysis), with SQL query and data validation experience supporting reimbursement analysis and payment integrity initiatives preferred.

• Demonstrated ability to lead cross-functional initiatives, communicate technical concepts to business stakeholders, manage multiple priorities, and deliver strategic reimbursement and clinical content solutions preferred. 

• Scaled Agile Framework (SAFe) experience preferred.

Job Level:

Workshift:

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Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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 review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.