Provider Reimbursement Manager

Elevance Health; Grand Prairie (TX); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Elevance Health is seeking a Provider Reimbursement Manager to lead cost-of-care initiatives and shape the reimbursement strategy across plans. You will coordinate with actuarial, decision support and underwriting teams to ensure pricing aligns with corporate targets, while guiding complex fee modeling and provider negotiations.

This hybrid role requires on-site presence 1–2 days weekly; proximity to an Elevance Health office is preferred.

Qualifications

• 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 providing an equivalent background.
• CPC or CIC certification is preferred for consideration.
• Experience with post-pay reviews, validation and recovery processes is strongly preferred.
• Experience managing multiple projects in various stages to completion is strongly preferred.
• Experience with claim processing and adjustment is strongly preferred.

Responsibilities

• Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
• Works with Health Service Area, actuarial, decision support, and underwriting to ensure cost of care targets are incorporated into pricing and financial plans.
• Performs and/or directs complex fee modeling exercises to ensure projected unit reimbursement changes meet targets.
• Provides analytical support for hospital and physician negotiations.
• Prepares and presents cost of care data analysis to support regional cost of care initiatives.
• Develops and maintains the provider reimbursement strategy to lower cost of care and improve service.

Skills

Financial modeling

Economic analyses

Stakeholder communication

Project management

Education

BA/BS degree

Tools

WGS

GBD Facets

Job description

Provider Reimbursement Manager

LOCATION: This is a hybrid role. Eastern or Central time zone highly preferred. You should be within a reasonable proximity to an eligible office.

HOURS: General business hours, Monday through Friday.

Hybrid -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.

The Provider Reimbursement Manager manages key components of the provider reimbursement strategy.

Primary duties may include, but are not limited to:

• Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules.
• Works with the Health Service Area, actuarial, decision support, and underwriting to ensure that accurate cost of care targets are incorporated into product pricing and the company's financial plans.
• Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets.
• Provides analytical support for hospital and physician negotiations.
• Prepares and presents cost of care data analysis to support the regions cost of care initiatives.
• Develops and maintains the provider reimbursement strategy that will lower the cost of care, improve service, and reduce administrative expenses.
• Manages special projects and initiatives.

Required Qualifications

• 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 Qualifications

• You must be CPC or CIC certified to be considered for this position.
• WGS and/or GBD Facets experience preferred.
• Experience working post-pay reviews, validation, and recovery processes in the healthcare industry strong preferred.
• Experience managing multiple projects in various stages to completion strongly preferred.
• Claim processing and adjustment experience strongly preferred.
• You should be comfortable speaking to external stakeholders to present concepts, and be an SME on CoC.

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 Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) 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 (https://info.flclearinghouse.com/) .