Healthcare Process Expert Sr.

Anticipated End Date:

2025-06-30

Position Title:

Healthcare Process Expert Sr.

Job Description:

Locations:  Columbus OH, Cincinnati OH, Mason OH, Seven Hills OH

Hours: Monday - Friday

Travel: Hybrid: This role requires associates to be in-office [1] day per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

Position Overview:

Supports claims oversight and operations for a Fully Integrated Dual Eligible (FIDE) program. Accountable for ensuring Prompt Pay requirements are met and reported according to State regulator contract standard. Collaborates with all plan departments to identify, report and resolve configuration issues in a timely fashion.

How You Will Make an Impact:

• Research claims operations workflow problems and system irregularities

• Collaborates across plan departments including but not limited to provider experience, program integrity, call center, utilization management to identify and resolve claims issues.

• Develops, tests, presents claims adjudication solutions for primary and secondary claims in a crossover model.

• Develops and reports claims projects for issues impacting multiple providers

• Provides process direction and decision making for all minor and major project work

• May perform duties as a lead when involved with enterprise-wide initiatives/projects

• Monitors and reports on Prompt Pay claims results to regulators

Required Qualifications:

• Requires a BA/BS and minimum of 8 years’ experience in business analysis, process improvement, project coordination in a high-volume managed care operation (claims, customer service, enrollment and billing); or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications:

• Understanding of medical claims in Medicare and Medicaid strongly preferred

• Experience in a FIDE or MMP plan strongly preferred

• Ability to work collaboratively across plan departments preferred

• Experience effectively communicates with leadership on metrics and escalated issues preferred

• Experience developing workflows, processes, supporting systems and procedures and identifying improvements strongly preferred

• Project management or lean six sigma certification is nice to have

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

BSP > Process Improvement

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.

The health of our associates and communities is a to