Clinical Documentation and Claims Integrity Director

Anticipated End Date:

2025-08-22

Position Title:

Clinical Documentation and Claims Integrity Director

Job Description:

Clinical Documentation and Claims Integrity Director

Location: Alternate locations may be considered. This position will work a hybrid model (remote and office). The ideal candidate will live within a commutable distance from our PulsePoint locations. 

CareBridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. CareBridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services.

The Clinical Document Improvement Director is responsible for leading encounter processing, diagnostic documentation and claims integrity across CareBridge. The ideal candidate has experience working in leading healthcare payer claims/ revenue cycle management (RCM) organizations, with specific understanding in end-to-end claims/ encounter processing, as well as ensuring compliance with Medicare/ Medicaid regulatory policies regarding FFS and zero-dollar claims.

How you will make an impact:

• Refine and build new infrastructure for end-to-end claims integrity, including associated reporting and KPIs.

• Oversees design and execution of provider/chart review workflows to ensure high quality encounter submissions.

• Liaises with senior CareBridge and Elevance Health leadership across Product, Analytics, and Clinical Operations teams.

• Advises on vendor investments and operational best practices to support optimal encounter submissions and diagnostic documentation.

Minimum Requirements:

• Requires BA/BS and a minimum of 5 years of related experience, including 3 years of hands-on HCC coding, chart review, and RAF calculations; or any combination of education and experience which would provide an equivalent background.

• Requires experience using RADV protocols and following Center for Medicare and Medicaid Services (CMS) and Affordable Care Act (ACA) rules.

Preferred Skills, Capabilities, and Experience:

• Experience working with encounter data systems within a healthcare payer or RCM organization and associated coding/ claim integrity certifications strongly preferred.

• Experience working with Medicare/ Medicaid and associated claims return files strongly preferred.

• MPH, MHA, MBA, or MSN preferred.

• Process improvement certification such as Six Sigma strongly preferred.

• KPI work experience in synthesizing large data sets/ interpreting KPIs to inform clinical and operational improvement strongly preferred.

• Experience engaging with senior leadership strongly preferred.

• Excellent written, oral, presentation and interpersonal communication skills with the proven ability to negotiate preferred.

• Proficient of Microsoft Office products, most notably in PowerPoint, Teams, Outlook, Excel, and Word, strongly preferred.

Job Level:

Director Equivalent

Workshift:

1st Shift (United States of America)

Job Family:

MED > Clinical Quality (Non-Licensed)

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