Provider Reimburse Admin Sr

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 Networ

X.

• Reviewing provider contracts to ensure compliance is 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 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.

• Requires a BA/BS degree and a minimum of 4 years related experience; or any combination of education and experience that would provide an equivalent background.

• Experience with FACETS Networ
  
  X configuration is 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.

Job Details

Anticipated End Date:

Position Title: Provider Reimburse Admin Sr

Hours: Monday - Friday

Location: Norfolk VA, Richmond VA, Wallingford CT, Durham NC, Atlanta GA, Indianapolis IN, Mason OH, Grand Prairie TX

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.

Note:

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.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: PND >
Pricing Configuration

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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…