Rating/Claims System Senior Advisor

Location: This position will work a hybrid model (remote and office). The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations in Columbus, OH; Mason, OH; Indianapolis, IN; Chicago, IL; Manchester, NH; Boston, MA.

The Rating/Claims System Senior Advisor leads the activities for India based Commercial Claims Operations, Claims System Configuration, and Provider Data Management departments to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achievement of cost objectives and service level goals; provider data management and related downstream processes; collaboration with all other client departments to ensure client goals are achieved and compliance with guidelines are met.

How you will make an impact:

• Establish standards of performance, including training, policies and procedures, claims auditing and other performance measurement techniques.
• Oversee all activities related to claims processing.
• Primary oversight and responsibility for delegated claims functions performed by third party vendor, including claims processing and fulfillment.
• Oversee the coordination of procedures for administering the various benefit plans and provider contracts with all interfacing systems.
• Responsible for implementing and auditing benefit changes as related to claims processing.
• Responsible for monitoring Medicare changes as they relate to claims payment and methodologies, benefits and coding and billing.
• Develop and implement cost control measures.
• Responsible for directing the processing and payment of claims.
• Provides guidance on the most complex claims.
• Develops short/long-term objectives and continually monitors procedures to ensure these are met by staff.
• Stays abreast of state/federal regulations.
• Manages commercial claims processing team located in CGS’s India site.
• Works with business owners to identify and analyze requirements and processes with Information Technology and the vendor to ensure quality and timeliness of systems/project deliverables.
• Position requires significant and regular external contact with customers or regulatory agencies.
• Has significant budget accountability and manages special projects.
• Translates the most highly complex and varied business needs into application software functionality.
• These needs typically involve a significant expenditure or cost savings and impact a wide range of functions.
• Configures new designs/updates in the system.
• Monitors system and business functionality and performance.
• Documents and tracks product defects.
• Coordinates problem resolution with development and/or product vendors.
• May implement rates, rating formulas, product and benefit configuration/information and as directed by the appropriate business unit.
• Analyzes, develops and validates data.
• Researches, documents and completes very diverse and complex projects and work processes to ensure business continuity and consistency.
• Formulates and defines system scope and objectives based on user-defined requirements.
• Supports and maintains the systems post-implementation.
• Provides end user support, consultation, liaison communications, helpdesk triage, training, reporting, auditing, application security, and ad hoc inquiries and requests.
• Provides expertise to lower level analysts.

Minimum Requirements:

Requires an BA/BS degree in Information Technology, Computer Science or related field of study and a minimum of 8 years systems analyst or business analyst experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• 8-10 years of leadership and Managed Care experience, preferably in Medicare Advantage strongly preferred.
• Experience working closely with offshore IT support team strongly preferred.
• Experience with Medicare and corresponding regulatory requirements preferred.
• Comprehensive knowledge of the health insurance industry, including, but not limited to: claim adjudication procedures; insurance law; benefit design; plan document provisions and compliance regulation strongly preferred.
• Excellent analytical ability, written, oral and interpersonal communication skills, negotiation skills, PC skills, advanced strategic planning, organizational, managerial and leadership skills strongly preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health 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 elevancehealthjobssupport@elevancehealth.com for assistance.