Jobs at Elevance Health

Processes moderately complex prescriptions and prior authorization requests, verifies member, provider, and drug information, and troubleshoots adjudication issues. Assists with configuring and quality-checking prior authorization decision trees, implementing clinical programs, and ensuring Medicare and Medicaid compliance. Communicates determinations to relevant parties and educates providers about pharmacy rules, medication resources, and assistance programs.

Manages small to medium projects from initiation through closeout, including charters, schedules, budgets, communications, team coordination, issue resolution, scope changes, testing, quality reviews, approvals, and deployment planning. Partners with sponsors and business stakeholders to align projects with organizational goals, monitor ROI, and report progress. The role requires at least three years of project management experience, including two years leading project tasks, and is based in San Juan or Mayaguez, Puerto Rico with a hybrid schedule.

Conducts provider audits by reviewing medical records, bills, contracts, claims, and reimbursement policies. Selects claims and providers for review, identifies billing anomalies and potential abuse, validates overpayments, presents findings, and prepares audit reports. The role also mentors auditors, develops policies and educational materials, and represents the audit function on task forces and committees.

Reviews and processes customer grievances and appeals involving claims, benefit coverage, eligibility, and administrative policies. Investigates cases, gathers information from customers, documents interactions, prepares written correspondence and review files, and triages clinical and non-clinical inquiries. Summarizes cases for clinical specialists, medical directors, legal counsel, and grievance committees, while making administrative appeal decisions within established guidelines.

Manages Ohio Medicaid claims programs, including claims configuration issues, rate changes, regulatory and contractual updates, reporting, compliance, adjudication, provider payment accuracy, and dispute resolution. Coordinates cross-functional teams and external client relationships, supports state and executive stakeholders, develops program success measures, and oversees end-to-end claims performance and regulatory reporting.

Provides telephonic care management for members with complex and chronic conditions. Assesses needs, develops and implements care plans, coordinates referrals and resources, facilitates discharge planning, monitors outcomes, and collaborates with providers, Medical Directors, and Physician Advisors to resolve care, claims, and service issues.

Builds relationships with manufacturer representatives, physician office staff, and referral sources to promote specialty pharmacy services. Develops and executes territory sales plans, therapy targeting, routing, and call cycles; analyzes prescribing patterns; responds to referral inquiries; maintains product knowledge; and collaborates with operations and leadership to achieve territory results. This field-based role covers the San Antonio-Houston territory and requires travel of up to 50% overnight.

Provides telephonic and on-site care management for members with complex or chronic needs. Assesses members, develops and monitors care plans, coordinates internal and external resources, facilitates authorizations and referrals, collaborates with medical directors and providers, supports discharge planning, and resolves claims or service issues. The role requires an active RN license and clinical experience, with OB/NICU, managed care, case management, and Spanish bilingual experience preferred.

Serve as liaison between business and IT to translate pharmacy benefit requirements into system design and tests. Validate formulary, utilization management, and drug list setups using claims/query testing, triage defects, collaborate with cross-functional teams, develop project plans, and support test automation and reporting.

Leads enterprise application architecture and end-to-end technology delivery. Defines architecture visions, evaluates technology solutions, translates business requirements into technical designs, oversees development and testing, and establishes architectural standards. Provides consulting and direction across complex initiatives while integrating AI, applications, APIs, data, cloud, and legacy platforms. Guides engineering partners, drives production readiness, and develops reusable enterprise capabilities with security, privacy, compliance, observability, reliability, and human oversight embedded throughout delivery.

Creates and manages provider contract templates, ensuring compliance with federal, state, and regulatory requirements. Reviews and recommends contract language changes, evaluates modifications, supports negotiations, researches financial and operational impacts, maintains contract tracking tools, and develops resources for contract negotiators. Collaborates with Legal, provider contracting leadership, negotiators, and governing committees to approve and implement effective contracts.

Manages specialty pharmacy operations, including pharmacist and technician performance, patient care coordination, dispensing, delivery, inventory, billing support, authorizations, clinical outcomes, accreditation programs, and specialty pharmacy account management. Provides pharmaceutical care, staff training, operational leadership, and performance oversight while maintaining compliance and supporting patients throughout intake, treatment, and drug distribution.

Processes and enters basic prescriptions, verifies member information, troubleshoots adjudication issues, and supports pharmacists. The technician interprets prescriptions, charts, lab notes, and ICD-10 codes; educates members about pharmacy rules and assistance programs; resolves grievances and appeals; and responds to provider, sales, and member inquiries about formularies and prescription benefits.

Audits complex inpatient medical records and DRG-coded claims to identify recoverable payment errors. Applies advanced ICD-9/10-CM, DRG, clinical, and coding guidelines; prepares audit findings and dispute documentation; performs secondary audits and validates lower-level auditor quality. Independently handles highly complex cases, identifies new recovery opportunities, recommends process improvements, and collaborates with management on audit selection criteria.

Supports reporting, analytics, troubleshooting, and process improvement across the claims lifecycle. Builds claims and encounter reporting, reconciles data, develops self-service tools, supports payer onboarding and configuration validation, resolves submission issues, and partners with Product, Engineering, Finance, and Operations. The role requires expertise in provider-side claims, EHR and revenue cycle systems, SQL, claim formats, clearinghouse workflows, and BI reporting.

Lead a regional team of Pharmacy Account Executives and Account Managers to drive client retention, profitability, and satisfaction for CarelonRx clients. Partner with health plan leadership and cross-functional teams to execute market strategies, resolve complex client issues, monitor regional performance, and ensure operational delivery. Hire, train, coach, evaluate staff, and oversee reporting and initiatives to support growth and client commitments.

Supports Carelon Payment Integrity change initiatives, process enhancements, documentation, data entry, activity tracking, and communications. Prepares newsletters, dashboards, presentations, and claims accuracy insights; promotes payment accuracy efforts and helps coordinate cross-functional work across Claims, SIU, Clinical Review, and Operations. The role also supports performance improvement, operational reporting, and leadership decision-making through clear, accurate information.

Conducts financial and operational audits, internal control assessments, risk evaluations, strategy reviews, and special projects. Leads audit planning, testing, documentation, findings remediation, and retesting across enterprise functions. Collaborates with business leaders and external auditors, validates data, reviews other auditors’ work, and trains less experienced staff. Requires a related bachelor’s degree and at least three years of relevant experience or equivalent public accounting experience.

Maintains enterprise information security policies, standards, and procedures while designing and supporting secure network, access control, cloud, data protection, and messaging solutions. Provides hands-on support for Protegrity, Terraform, Kubernetes, Splunk, ServiceNow, Snowflake, HashiCorp Vault, and HSMs. Troubleshoots integrations, manages infrastructure and secrets, supports incident and change workflows, and ensures complex security solutions comply with enterprise, regulatory, and industry standards.

Oversee patient check-in, registration, and checkout processes at an onsite infusion clinic. Verify charts, update demographics and eligibility, maintain current forms, address patient and family concerns, route questions and complaints, analyze administrative operations and resource utilization, assist with Medic system issues, and ensure cash-control policies are followed.