Clinical Documentation and Claims Integrity Director

Anticipated End Date:

2025-10-02

Position Title:

Clinical Documentation and Claims Integrity Director

Job Description:

Clinical Documentation and Claims Integrity Director

Location: Virtual:  This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

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 Documentation and Claims Integrity Director will lead CareBridge’s efforts in diagnostic documentation and claims integrity. This leader brings proven experience in payer and provider risk adjustment initiatives and possesses a deep understanding of end-to-end claims and encounter processing (including both fee-for-service and “zero-dollar” models). The ideal candidate may have also successfully scaled similar operations at a start-up—such as a value-based care provider or a healthcare services enablement company—and is well-versed in Medicare and Medicaid risk adjustment policies, RADV auditing, and the infrastructure that underpins claims delivery.

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 and disease documentation.

• 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.

• Preferred qualifications include an MPH, MHA, MBA, or MSN, or alternatively, training or certifications in health information technology.

• Process improvement certification such as Six Sigma strongly preferred.

• 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.