Senior Advisor, Account Management
Elevance Health
Medical Claims Data Integrity Consultant
Elevance Health
full-time
Posted on:
Origin: • 🇺🇸 United States • Illinois, Kentucky, Virginia
Visit company websiteSalary
💰 $129,888 - $194,832 per year
Job Level
Mid-LevelSenior
About the role
- Focus on AI to streamline processes and design solutions to prevent FWA and over-payment
- Undertake complex assignments requiring specialized technical knowledge
- Conduct extensive research on CMS regulations, internal/external reimbursement, and medical/clinical policies, supporting findings with official documents
- Establish and communicate common goals and direction for the team
- Establish and maintain advanced knowledge of data warehouse database design, data definitions, system capabilities, and data integrity issues
- Act as a source of direction, training and guidance for less experienced staff
- Analyze pertinent claims and medical records and present findings
- Develop and support very complex Data Warehouse-related applications for business areas, including design and implementation of database tables
- Conduct training on the use of applications developed
- Maintain current industry knowledge of claim edit references, including AMA, CMS, and NCCI
Requirements
- Requires a BS/BA degree; minimum of 6 years experience; or any combination of education and experience
- Not eligible for current or future visa sponsorship
- Associates required to be in-office 1 - 2 days per week; candidates must reside within commuting distance or receive an accommodation
- Experience with Enterprise Data Assets like CDP and AEDL is a plus
- Operational system knowledge (WGS, GBD FACETS)
- Clinical Review experience evaluating clinical content, documents, and protocols for accuracy and relevance
- Capability to apply industry coding guidelines to claims processes
- Demonstrated experience reviewing, analyzing, and researching coding issues and data reports to establish patterns for payment integrity
- Solid understanding of the claims workflow and its interconnection with claim forms
- Experience with Payment Integrity background
- Maintains current industry knowledge of claim edit references (AMA, CMS, NCCI)
- Advanced knowledge of data warehouse database design, data definitions, system capabilities, and data integrity issues
- Strong analytical skills with ability to present findings and content value to internal and external contacts
- Experience developing and supporting complex Data Warehouse-related applications and conducting training
