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.
Preferred Qualifications: - 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
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee
Job Level:Non-Management Exempt
Workshift:1st Shift (United States of America)
Job Family:PND > Pricing Configuration
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.
