Manager, Clinical Content – Reimbursement

Elevance Health

Manager of Clinical Content & Reimbursement at Elevance Health. Responsible for developing clinical content scope in alignment with product and operational targets.

Posted 4/29/2026full-timeNorfolk • Florida, Tennessee, Virginia • 🇺🇸 United StatesSeniorLeadWebsite

About the role

Key responsibilities & impact

Driving the development and execution of the clinical content scope in alignment with the product and content strategy to meet financial and operational targets
Researching and interpreting CMS, CPT/AMA and other major payer policies based on medical coding and regulatory requirements
Identifying common error areas that can be made into automated software logic to prevent overpayments from occurring
Taking edits from concept to specification and then through review, testing and finally data validation
Developing claims editing logic and content that promote payment accuracy and transparency
Leading fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules
Working with business partners to assist with cost of care claim editing goals
Performing and/or directing complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets
Reviewing healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that can be turned into software editing rules
Creating billing edits that provide clients with monetary savings and promote coding accuracy
Preparing and presenting cost of care data analysis to support the regions cost of care initiatives
Developing and maintaining the provider reimbursement strategy that will lower the cost of care, improve service, and reduce administrative expenses
Managing special projects and initiatives

Requirements

What you’ll need

Requires a BA/BS degree in a related field
Minimum of 7 years reimbursement experience including performing detailed financial modeling and economic analyses
5+ years of claims editing experience with healthcare payers and/or claims editing software vendors, strongly preferred
Billing, coding, revenue cycle, and claims editing software experience
Nationally recognized coding or billing credential required: CCS, CCS-P, CPC, CPB, CIC
Experience in claims adjudication and application of NCCI editing and claims payment rules
Ability to interpret claim edit rules and references
Solid understanding of claims workflow including the interconnection with claim forms
Ability to apply industry coding guidelines to claim processes
Proven experience reviewing, analyzing, and researching coding issues for payment integrity
Logic skills: ability to break policy edits down into decision making paths
Ability to troubleshoot and apply root-cause analysis of logics not functioning as intended
Intermediate level proficiency in Excel (ability to manipulate data using excel functions along with pivot tables, v-look up, etc.)
Strong ideation skills
Inpatient coding skills highly preferred

Benefits

Comp & perks

Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical benefits
Dental benefits
Vision benefits
Short and long term disability benefits
401(k) +match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims editingbillingcodingrevenue cyclefinancial modelingeconomic analysesclaims adjudicationNCCI editingdata validationinpatient coding

Soft Skills

troubleshootingroot-cause analysisideationresearchinginterpretingleadingpresentinganalyzingcollaboratingproblem-solving

Certifications

CCSCCS-PCPCCPBCIC