Clinical Content Analyst

Location: This position will work a hybrid model (remote and in office one day per week). Ideal candidates will live within 50 miles of one of our Pulse Point locations in Atlanta, GA, Wilmington, DE, Tampa, FL, Indianapolis, IN, Durham, NC, Norfolk, VA, Richmond, VA, Mason, OH, Cincinnati, OH, St. Louis, MO, Wallingford, CT, Grand Prairie, TX or Louisville, KY.

The Clinical Content Analyst will be responsible for driving the development and execution of the clinical content scope in alignment with the product and content strategy to meet financial and operational targets. The Clinical Content Analyst role will research and interpret CMS, CPT/AMA and other major payer policies based on healthcare correct coding and regulatory requirements.

How you will make an impact:

• Oversees the conception and development of new content.

• Takes edits from concept to specification and then through review, testing and finally data validation.

• Develops claims editing logic and content that promotes payment accuracy and transparency across Medicaid, Medicare, and Commercial lines of business.

• Identifies common error areas that can be made into automated software logic that prevent overpayments from occurring.

• Provides data-based reports and recommendations to optimize content performance and guide content strategy.

• Reviews healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that can be turned into software editing rules.

• Creates billing edits that provides clients with monetary savings and promote coding accuracy.

• Uses structural design to turn policy language into specifications that developers turn into software coding edits or logic.

• Builds unit tests to verify the functionality of the edits.

• Applies revenue cycle, coding, and billing expertise to interpret policy based on correct coding, billing, and auditing guidelines.

• Provides in-depth research on regulations and support edits with official documents.

• Validates if edits are working as intended and support decisions with validation data.

• Presents to business partners (internal/external) to demonstrate the content value.

• Maintains current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI.

• Collaborates with the Content and Engineering and Data teams to develop, adjust, and validate edits.

• Meets weekly productivity and quality goals.

• Curates source content.

• Develops and maintains the content plan, owns and manages content maintenance plan to ensure content supports strategy.

• Contributes to a core center of excellence for digital editing content.

• Serves as a lead role and have dotted line resource accountability.

• Directs and supervises the conception and development of new content.

Minimum Requirements:

Requires a BA/BS in a related field and a minimum of 5 years of related experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Master’s Degree strongly preferred.

• Scaled Agile Framework Training strongly preferred.

• 5+ years of claims editing experience with healthcare payers and/or claims editing software vendors, strongly preferred.

• Billing, coding, revenue cycle, and claims editing software experience strongly preferred.

• Nationally recognized coding or billing credential required: CCS, CCS-P, CPC, CPB strongly preferred.

• Experience in claims adjudication and application of NCCI editing and claims payment rules strongly preferred.

• Ability to interpret claim edit rules and references strongly preferred.

• Solid understanding of claims workflow including the interconnection with claim forms strongly preferred.

• Ability to apply industry coding guidelines to claim processes strongly preferred.

• Proven experience reviewing, analyzing, and researching coding issues for payment integrity strongly preferred.

• Ability to break policy edits down into decision making paths preferred.

• Ability to troubleshoot and apply root-cause analysis of logics not functioning as intended preferred.

• Intermediate level proficiency in Excel (ability to manipulate data using excel functions along with pivot tables, v-look up, etc) preferred.

• SQL query-building and lookup skills 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.