Anticipated End Date:

2026-03-13

Position Title:

Carelon Payment Integrity Manager

Job Description:

Carelon Payment Integrity Manager

Location: 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 Carelon Payment Integrity Manager is responsible for supporting Project Raven implementation and governance, including aligning regulatory requirements with system configuration, validation activities, and operational workflows. The Compliance Manager partners with cross-functional stakeholders to ensure system logic, lookback requirements, provider exceptions, and recovery processes are compliant with state and federal requirements across multiple markets. The Compliance Manager serves as a key leader within the Carelon Insights Payment Integrity Regulatory Compliance (PIRC) organization, supporting both Project Raven and broader compliance initiatives across Medicaid and Commercial lines of business. This role is responsible for managing foundational and strategic compliance activities that ensure regulatory adherence, operational integrity, and effective oversight of payment accuracy programs. The Compliance Manager serves as a trusted advisor within Payment Integrity, strengthening regulatory alignment and supporting continuous improvement across the organization.

How you will make an impact:

• Provide strategic oversight for regulatory audits, internal audits, risk assessments, and compliance reviews across Medicaid and Commercial programs.
• Support Project Raven through validation oversight, regulatory alignment, issue tracking, and coordination between compliance, operations, IT, and data teams.
• Ensure the accuracy of claims payment through structured prevention, detection, and correction processes addressing billing, payment, and membership errors.
• Evaluate regulatory changes and health care reform updates to determine operational impact and necessary compliance actions.
• Develop and execute audit plans, conduct gap analyses, oversee audit preparedness, and coordinate evidence collection.
• Serve as a subject matter expert on applicable laws and regulations impacting Payment Integrity and fraud, waste, and abuse (FWA).
• Monitor compliance plan provisions, investigate unusual incidents, and implement corrective action plans as needed.
• Oversee key compliance tools and systems, including CONTRAXX, Doctract, ServiceNow (SNOW), SharePoint, and related governance platforms.
• Manage compliance mandates, project plans, milestone tracking, and leadership reporting.
• Partner with Health Plan leaders, regulators, vendors, and internal governance teams to ensure consistent adherence to compliance standards.
• Develop processes to detect systemic operational inefficiencies and mitigate regulatory risk.
• Analyze and report monthly compliance and payment integrity performance metrics.

Minimum Requirements: Requires a BA/BS in business, engineering, nursing, finance, or healthcare administration and minimum of 5 years related work experience, including minimum of 2 years’ leadership experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• 5+ years of healthcare, regulatory, ethics, compliance, privacy, or payment integrity experience preferred; regulatory compliance experience strongly preferred.
• 2+ years of project management experience strongly preferred.
• Advanced degree (MS, MBA, JD) or professional certification (e.g., CHC, CCEP, CHPC).
• Demonstrated experience leading complex compliance programs, audits, or large-scale regulatory initiatives preferred.
• Experience supporting Medicaid and Commercial compliance programs preferred.
• Strong analytical, communication, and cross-functional leadership skills preferred.
• Familiarity with regulatory compliance reporting preferred.
• Experience working with compliance and operational systems such as SharePoint, Doctract, CONTRAXX, ServiceNow, and claims platforms.
• Smartsheet experience preferred.
• Adapts easily to learning new systems preferred.

Job Level:

Non-Management Exempt

Workshift:

Job Family:

FRD > Compliance

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.

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 and Influenza. 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 [email protected] for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.