Carelon Medical Coding/Auditing Manager - Behavioral Health at Elevance Health

Hanover, Maryland, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Insurance, Behavioral HealthIndustries

Requirements

BA/BS in business, engineering, nursing, finance, or healthcare administration
Minimum of 5 years related work experience
Minimum of 2 years leadership experience (or equivalent combination of education and experience)
Located in Maryland (must be within reasonable commuting distance; in-office 3-4 days per week)
Detailed technical knowledge of claims payment accuracy

Responsibilities

Ensure accuracy of claims payment through management of processes for prevention, detection, and correction of billing, payment, and membership errors
Work with health plan leaders and oversee monitoring and enforcement of fraud, waste, and abuse compliance program per state and federal regulations
Participate on cross-functional teams focused on problem remediation and long-term resolution
Anticipate effects of changes in the business environment on future claim errors
Evaluate regulatory compliance and Health Care Reform changes for potential impact
Evaluate provider activities to assist in detection of fraud, waste, and abuse
Monitor provisions of the compliance plan, including fraud, waste, and abuse policies and procedures
Investigate unusual incidents and implement corrective action plans
Develop and analyze monthly reports
Develop project plans and oversee project execution, issue management, and progress reporting
Develop processes to support early detection of systemic issues causing operational inefficiencies

Skills

Medical Coding

Auditing

Claims Payment

Payment Integrity

Fraud Detection

Waste Abuse Compliance

Billing Errors

Regulatory Compliance

Behavioral Health

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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