Provider Reimbursement & Prepay Editing Director

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Anticipated End Date: 2026-07-11 Position Title: Provider Reimbursement & Prepay Editing Director Job Description: Provider Reimbursement & Prepay Editing Director Hybrid 2: This role requires associates to be in-office 3 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. Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center-connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. The Provider Reimbursement & Prepay Editing Director is responsible for leading key provider reimbursement and prepay editing functions and initiatives across the enterprise and serves as subject matter expert regarding provider reimbursement strategies, reimbursement policy implementation, and claims editing practices. How You Will Make an Impact Primary duties may include, but are not limited to: Leads the development and implementation of enterprise-wide provider reimbursement strategies, processes, systems, and prepay editing initiatives for a major provider type, such as facilities. Works to drive the adoption and use of standardized reimbursement, claims editing, and reimbursement policy methodologies across the enterprise. Works with medical directors, contract negotiators, coding teams, cost of care staff, payment integrity partners, and provider relations staff to identify and implement best practice solutions to manage costs and reimburse services appropriately. Facilitates the communication of activities, emerging trends, reimbursement policy updates, and best practices across all units and facilitates implementation of initiatives through use of a steering committee containing representatives from the company's plans, regions, and business units. Researches and quantifies the impact of changes to reimbursement methodologies, reimbursement policies, and claims editing initiatives. May lead fee schedule development for specific plan(s) and/or the development, implementation, and oversight of clinical editing rules and reimbursement edit governance activities. Supports operational quality improvement initiatives, including defect management, issue resolution, and root cause analysis related to claims editing and reimbursement activities. Manages special projects and initiatives related to provider reimbursement, payment integrity, and prepay editing operations. Represents the department and serves as a key contributor on enterprise initiatives, projects, audit activities, and task forces. Minimum Requirements: Requires a BS/BA degree in a related field and a minimum of 10 years business and professional experience in provider reimbursement and contracting, provider relations, and provider servicing; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities, & Experiences: 8-12+ years of experience in provider reimbursement, payment integrity, claims editing, reimbursement policy implementation, or prepay editing operations preferred. Strong knowledge of prepay editing methodologies, reimbursement policy interpretation, and claims editing governance preferred. Experience supporting reimbursement edit implementation, maintenance, defect management, and operational quality initiatives preferred. Professional coding certification such as CPC, CCS, RHIT, or equivalent coding certification or experience preferred. Strong understanding of reimbursement methodologies, medical coding principles, and payment integrity operations preferred. Experience working within complex matrixed healthcare organizations and leading cross-functional initiatives without direct authority preferred. Experience supporting audit, regulatory, and compliance activities related to provider reimbursement and claims editing operations preferred. Strong communication, analytical, problem-solving, and stakeholder management skills preferred. For candidates working in person or virtually in t

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