Medical Claims Data Integrity Consultant

Medical Claims Data Integrity Consultant

Location: Atlanta, GA; Norfolk, VA; Indianapolis, IN; Chicago, IL; Louisville, KY (preferred). This role requires associates to be in-office 1 - 2 days 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 if candidates reside within a commuting distance from an office.

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.

The Medical Claims Data Integrity Consultant (Business Information Developer Consultant Senior) is viewed as an expert in the development and execution of data mining analyses. This position is focused on spending time thinking about AI and how it would be used to streamline processes and design solutions to prevent FWA, over-payment, etc.

How you will make an impact:

• Undertakes complex assignments requiring additional specialized technical knowledge.
• Conducts extensive research on CMS regulations, internal and external reimbursement, and medical/clinical policies, while supporting the findings with official documents.
• Establishes and communicates common goals and direction for the team.
• Establishes and maintains advanced knowledge of data warehouse database design, data definitions, system capabilities, and data integrity issues.
• Acts as a source of direction, training and guidance for less experienced staff.
• Analyzes pertinent claims, medical records.
• Strong use of analytical skills with the ability to present findings and content value to internal and external contacts, clients, or customers.
• Develops and supports very complex Data Warehouse-related applications for business areas requiring design and implementation of database tables.
• Conducts training on the use of applications developed.
• Maintains current industry knowledge of claim edit references, including but not limited to AMA, CMS, and NCCI.

Minimum Requirements:

• Requires a BS/BA degree; minimum of 6 years experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Experience with Enterprise Data Assets like CDP and AEDL is a plus.
• Operational system knowledge (WGS, GBD FACETS).
• Clinical Review: experience evaluating clinical content, documents, and protocols for accuracy and relevance, and providing feedback and recommendations for improvements.
• Capability to apply industry coding guidelines to claims processes.
• Demonstrated experience in reviewing, analyzing, and researching coding issues and data reports to establish patterns for payment integrity.
• Possess a solid understanding of the claims workflow, including its interconnection with claim forms.
• Experience with Payment Integrity background.

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.