Jobs at Elevance Health

Manages provider participation changes, network adequacy, regulatory submissions, audits, and compliance initiatives for healthcare provider networks. Coordinates with providers, regulators, delegated entities, and internal teams to resolve complex issues, support continuity of care, maintain network compliance, and improve provider satisfaction and retention. Develops project plans, policies, reports, training materials, and remediation strategies while serving as a liaison for provider relationships and regulatory requirements.

Performs operational financial and policy activities, including interpreting procedures, entering and validating information in finance systems, maintaining internal controls, tracking reconciliations, updating compliance controls, and independently resolving complex workflow issues. The role may also handle inbound payment-related queues, group reinstatements, final balance collection, and customer service communications.

Provides enterprise-wide legal counsel on technology matters, including AI, SaaS, software as a medical device, data use, and digital health product development. Negotiates technology agreements, advises sales teams on RFPs, assesses regulatory risks, develops contract templates and negotiation playbooks, and supports risk mitigation, strategic legal analysis, and internal education.

Leads enterprise-wide business improvement consulting initiatives to increase organizational effectiveness and profitability. Coaches project teams on process, people, and systems assessment; establishes performance metrics; partners with Six Sigma and TQM initiatives; builds cross-functional relationships; and drives adoption of improved communication, measurement, and engagement practices. Requires significant consulting or process improvement leadership experience, Lean Six Sigma Black Belt certification, advanced analytics, and occasional travel.

Leads specialty pharmacy clinical strategy and daily operations, mentoring pharmacists and directing non-clinical associates. Oversees clinical programs, performance metrics, regulatory alignment, executive reporting, cross-functional initiatives, staffing models, and operational improvements. Partners with medical, pharmacy, analytics, payer, manufacturer, provider, and technology teams to improve patient outcomes, medication adherence, safety, access, quality, and cost-effective medication use.

Leads financial governance and portfolio management for a large technology investment portfolio. Responsibilities include annual and multi-year budgeting, forecasting, staffing and resource governance, cost center management, vendor funding oversight, compliance, financial dashboards, executive reporting, and investment analysis. Partners with technology, finance, HR, procurement, audit, and executive leadership to ensure funding alignment, financial transparency, and sound strategic decisions. Uses enterprise financial systems, analytics platforms, AI, Power BI, and Excel to improve reporting and forecasting.

Leads process improvement and continuous improvement initiatives for a business unit. Identifies opportunities, researches and implements best practices, develops performance metrics, consults internally, and creates enterprise-wide improvement plans. Requires extensive process improvement, planning, project management, business analysis, and leadership experience, with preferred expertise in PBM claims, SQL, Teradata, Python automation, vendor management, Lean Six Sigma, prior authorization, eligibility, and Salesforce.

Assists with Medicaid rate development, statistical analysis, actuarial pricing, valuation, forecasting, and projection models. Collects, refines, validates, and evaluates data for accuracy and reasonableness while supporting the Medicaid Pricing lead and performing preliminary actuarial analyses under limited supervision.

Manages HEDIS audit activities across business lines, coordinating internal teams, health plans, committees, and state or national auditors. Interprets NCQA, CMS, and state requirements; develops audit work plans, assigns resources, oversees quality studies, analyzes quality data, and reports findings and recommendations. The role ensures compliant HEDIS and CAHPS submissions and prepares departments for external audits through mock interviews and ongoing process oversight.

Evaluate medical necessity and appropriateness of outpatient behavioral health care (primarily ABA), conduct pre-certification, concurrent review and appeals, collaborate with providers/BCBAs and Medical Directors, mentor care management staff, and assist development of psychological/neuropsych testing programs.

Develop and manage provider networks through complex contract negotiations, relationship development, and provider servicing. Negotiate customized fee schedules and non-standard agreements with institutional, medical group, and ancillary providers. Mentor contracting staff, support network composition and managed care initiatives, collaborate on enterprise projects and sales presentations, draft contract documents, and prepare financial projections and analyses.

Processes basic prescription data, prior authorizations, adjudication issues, grievances, and appeals. Verifies member information, supports pharmacists, educates members about prescription benefits and assistance programs, and responds to physician, sales, and member inquiries. Maintains authorization and rebate records while generating utilization and other reports. Requires pharmacy technician certification and at least one year of pharmacy experience.

Audits inpatient medical records and claims to validate coding and DRG assignments, identify recoverable claims, and produce audit findings. Applies advanced ICD-10-CM expertise, clinical guidelines, and reimbursement knowledge across MS-DRG, AP-DRG, and APR-DRG. Reviews documentation for coding accuracy, identifies additional recovery opportunities, maintains audit quality standards, and recommends process improvements.

Manages external client-facing healthcare programs involving subcontractor network certification, provider access surveys, regulatory filings, network adequacy monitoring, corrective action plans, compliance updates, budgets, stakeholder relationships, training, and performance assessments. Requires coordination with corporate and regional business areas while ensuring program objectives and regulatory requirements are met.

Provides advanced sales and service support to Medicare brokers and regional sales managers. Responsibilities include broker communications, co-op advertising and health risk assessment campaign tracking, reporting, onboarding, training coordination, welcome kits, outbound campaigns, disenrollment support, information requests, and special projects. The representative also recruits non-Medicare brokers, coordinates meetings and webinars, and travels throughout Southern California to client or designated sites.

Assists with actuarial rate determination, statistical analysis, pricing, valuation, and forecasting models. Collects, validates, and refines data; applies actuarial tools; and communicates findings and recommendations to colleagues, business partners, and leadership. The role requires a bachelor’s degree and at least one SOA or CAS actuarial exam, with additional exams, analytical programming experience, and healthcare interest preferred.