Senior Advisor – Rx Claims & Adjudication (Business Architect)

Anticipated End Date:

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Job Description:

Senior Advisor – Rx Claims & Adjudication (Business Architect)

PLEASE NOTE: This position is not eligible for current or future visa sponsorship

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 Senior Advisor – Rx Claims & Adjudication (Business Architect) will be responsible for driving and completing the Business Architecture portion of business blueprints, including establishing guiding principles, defining capabilities, performing functional analysis/definition, analyzing and documenting the value chain, and assessing organizational impacts.

How you will make an impact:

• Serve as the enterprise Subject Matter Expert (SME) on pharmacy claims adjudication, benefit design, and pricing logic.
• Interpret complex adjudication outcomes and translate into clear business decisions.
• Identify adjudication defects, inconsistencies, and financial leakage risks.
• Support resolution of high-impact claims issues and escalations.
• Advise on claims platform configuration (e.g., rules, pricing logic, edits).
• Represent the organization in client discussions, audits, and SME panels.
• Participates in providing linkage to other Enterprise Architecture groups and models, and coordinate and align activities to achieve the future state capabilities in partnership with Business Relationship Management (BRM).
• Contributes to Reference architectures, Strategic Business Architecture (SBA) and Operational Business Architecture (OBA) that articulate a future state direction to optimize the value chain.
• Contributes to Business Architecture portion of business blueprints, including establishing guiding principles, defining capabilities, performing functional analysis/definition, analyzing and documenting the value chain, and assessing organizational impacts.
• Proposes ideas for performing enterprise wide functional analysis to identify areas for efficiencies or rationalization opportunities, and conduct ongoing analysis of business capabilities and how improvements to architecture components can best support capabilities.
• Executes a common process for how projects are assessed against business architecture artifacts and blueprints; incorporate into overall architecture governance process.
• Communicates and builds consensus equally effectively with more than one constituents, including business executives, technologists, end users, and operations.

Minimum Requirements: 

Requires an BA/BS degree in Information Technology, Computer Science or related field of study and a minimum of 5 years of experience in business analyst and strategic planning, IT operations, IT leadership strategic and technical architecture with a minimum of 3 years in organizational management as it related to information architecture; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Deep claims adjudication expertise, Pricing methodologies (AWP, MAC, GER, rebates), NCPDP standards and claim transactions.
• Understanding of PBM operations payer workflows and Claims adjudication platforms.
• Strategic advisory capability. Present confidently to leadership and external stakeholders.
• Ability to bridge business + technical discussions effectively.

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Workshift:

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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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.