Overview
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 Networ
X.
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.
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.
Experience with FACETS Networ
X configuration a MUSTDOFR (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
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…
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