Provider Reimbursement Manager

Requirements

• CPC, RHIT, or RHIA certifications preferred
• Deep, working knowledge of prepay editing within Elevance, including existing edit logic, workflows, and systems
• Strong understanding of correct coding initiatives (CCI), reimbursement policy, and claims editing best practices
• Direct experience interpreting and operationalizing state Medicaid guidelines, including translating regulatory language into actionable business rules
• Proven experience onboarding new Medicaid markets, including assessing state-specific requirements and implementing compliant prepay edit strategies
• Experience maintaining ongoing market-level compliance through continuous monitoring, gap identification, and remediation
• Ability to influence without authority and drive alignment across market leadership, operations, and enterprise teams
• Strong analytical and problem-solving skills, with the ability to connect regulatory requirements to financial and operational outcomes
• For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $80,940 to $153,360
• Locations: California; New York
• The salary range is the range Elevance Health in good faith believes is the range of possi

Benefits

Additional Information

Anticipated End Date: 2026-06-19 Position Title: Provider Reimbursement Manager Job Description: Location: Louisville KY, Indianapolis IN, Richmond VA, Atlanta GA, Mason OH, Woodland Hills CA, Grand Prairie TX, New York NY Hours: Standard Working hours 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. 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 accommodation is granted as required by law. Position Overview: Manages key components of the provider reimbursement strategy. Serves as the primary point of contact for assigned Medicaid markets, building strong, working relationships with market leaders and operational teams to drive alignment on prepay editing strategy. How You Will Make an Impact: Lead ongoing collaboration with markets to ensure prepay edit compliance with evolving state Medicaid guidelines , translating regulatory changes into actionable edit requirements Identify and drive opportunities to improve cost of care performance , including socializing new edit concepts, quantifying impact, and partnering with markets to remediate risk and implement changes Support onboarding of new Medicaid markets by conducting deep reviews of state-specific reimbursement rules, billing guidelines, and regulatory requirements , and translating them into prepay edit logic Maintain and continuously enhance a centralized repository of state-specific edit requirements , ensuring accuracy, traceability, and accessibility for stakeholders Act as a subject matter expert on prepay editing, reimbursement policy, and correct coding , providing guidance to internal partners and influencing decision-making Partner cross-functionally with clinical, coding, analytics, and technology teams to ensure edits are operationalized effectively and delivering expected outcomes Monitor performance and compliance across assigned markets, proactively identifying gaps and driving corrective action Assigned Medicaid markets are consistently compliant with state-specific requirements and aligned to enterprise prepay edit strategy Demonstrated improvement in medical loss ratio (MLR) driven by effective edit implementation and cost-of-care initiatives New markets are onboarded efficiently with minimal rework and strong alignment to state guidelines from day one Clear, well-maintained documentation of edit requirements that reduces ambiguity and accelerates implementation 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.

Your Match

How well this role fits your profile.

Company Intel

What employees say

Worked at Elevance Health (Anthem)? Share your experience