Anthem, Inc. Remote Provider Reimburse Administrator, Sr (Pricing Configuration) in Costa Mesa, California
SHIFT: Day Job
Job Title: Remote Provider Reimburse Administrator, Sr (Pricing Configuration) Location: Work From Home / Remote (Considering candidates throughout the United States)
Be part of an extraordinary team! We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
How you will make an impact: Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. Serves as subject matter expert regarding reimbursement policies, edits, and coding conventions.
Primary duties may include, but are not limited to:
Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.
Works with other departments on claims adjudication workflow development and business process improvements.
May lead the full range of provider reimbursement activities.
Leads projects related to provider reimbursement initiatives.
Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy
Translates medical policies into reimbursement rule. Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
Performs pre-adjudication claims reviews to ensure proper coding was used.
Serves as a mentor to less experienced administrators.
Ensures compliance is being maintained by adhering to SOX controls, State mandates, CMS guidelines, and the Provider contract.
Works with provider contracting staff when new/modified reimbursement contracts are needed.
Coordinates research and responds to system inquires and appeals
Follows-up to verify client satisfaction and to keep customers informed
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.
Preferred Skills, Capabilities and Experiences:
Intermediate or above proficiency with Facets and NetWorx is critical in this position and highly desirable.
Experience in pricing configuration is critical and highly desirable.
Proficiency using Microtsoft Suite, i.e. Excel and Powerpoint
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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem 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 may contact firstname.lastname@example.org for assistance.