Provider Reimbursement Admin Sr: Provider Operations Quality - Virtual - 97324

Company Name:

Anthem is one of the nation's leading health benefits companies and a Fortune Top 50 company. At Anthem, we are working together to transform health care with trusted and caring solutions.
Bring your expertise to our innovative culture where you will have the opportunity to make a difference in people's lives, and to take your career further than you can imagine.
This Provider Reimbursement Admin Sr. position will be supporting the work of the Provider Operations Quality team within the Government Business Division (GBD)'s Provider Operations department.
This team is responsible to ensure that claims payment and benefits are correctly configured in context of medical policies, reimbursement policies, clinical editing policies, CMS requirements and contract details. Accurate systems configuration ensures the correct adjudication of claims and processing of provider payments for the providers in our GBD managed care networks.
/Primary duties may include but are not limited to:/
Reviewing individual provider contracts together with Anthem and CMS guidelines to ensure compliant and accurate configuration of critical information systems.
Analyzing each new provider contract for coverage, policy, reimbursement development, and implications for system edits. (May also perform CPT/HCPCS code and fee schedule updates)
Responding to system inquiries and appeals-- primarily in order to troubleshoot claims adjudication issues related to configuration.
Conducting research of claims systems and system edits to identify issues and to audit claims adjudication for accuracy.
Performing pre-adjudication claims reviews (configuration testing) to ensure proper configuration was used.
Prepares correspondence to providers regarding coding and fee schedule updates.
Trains customer service staff on system issues.
Working with provider contracting staff when new/modified reimbursement contracts are needed.
Assisting with the analysis, documentation, configuration, and testing of current and future markets business requirements.
Supporting the upgrade of test environments.
Work with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.
Work with other departments on claims adjudication workflow development and business process improvements.
May lead the full range of provider reimbursement activities for a state(s).
Lead projects related to provider reimbursement initiatives.
Serve as a mentor to less experienced administrators.
Local candidates may be able to report to our Norfolk, VA location, space allowing. This opportunity will offer flexibility in location to include full-time Work@Home.
Please note that relocation benefits are not offered at this time .
This exempt level individual contributor position is eligible for an Annual Incentive.
BA/BS degree; 4-6 years related experience; o r any combination of education and experience, which would provide an equivalent background.
Demonstrated knowledge and experience in the following areas is required for the role and must be included in the related or equivalent experience to meet the basic qualifications listed above:
o Leading or taking a primary role in the configuration of enterprise-class information systems/ software products in a highly regulated business environment
o Quality auditing experience
o Experience working with complex data to identify quality issues and surface root causes
o Providing feedback to associates/ their leaders related to findings of quality audits you have performed
o Experience in analysis and design of billing/ collection or similar applications and complex relational databases
o Care payer operations to include claims processing, claims auditing, claims testing and/ or claims research
o Direct experience in healthcare provider configuration
o Facets pricing configuration build experience
o Must know how to read and analyze a contract (physician, ancillary and hospital)
o Must have Facets NetworX experience
/ Preferred: /
Medicaid/ Medicare experience
Able to implement PCA's and load fee schedules
Able to run Microsoft access queries in relation to Facets
Project management experience
Knowledge of CPT/HCPCS coding
/Anthem is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine, and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at// //. EOE. M/F/Disability/Veteran./
Job Provider Network Management
Title: Provider Reimbursement Admin Sr: Provider Operations Quality - Virtual - 97324
Location: AZ-Scottsdate
Other Locations: VA-Norfolk
Requisition ID: 97324

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