Provider Escalations Analyst

Provider Escalations Analyst

Provider Escalations Analyst

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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 Provider Escalations Analyst is responsible for Provider Issues Resolution (PIR) escalations across all lines of business and is responsible for the resolution of provider payment escalation requests and communication of contracts along with medical and clinical policies.

How you will make an impact:

• Remediate impacted high dollar multi claim issues (request, analyze and adjust claim impact reports & initiate sweeps), investigate the outcome of claim payment or denial for provider escalations through the PIR support process.
• May adjust claims for a specific line of business and market within guidelines to ensure proper adjudication, interpret benefits, policies and procedures, provider contracts, and adjudication of claims, analyze systems and processes that span across multiple operational area and claim systems.
• Recommend resolution for contract dispute, non-routine claim issues, billing questions and other practices.
• Identify barriers and participates in process improvement projects and coordinates communication processes on medical policy, reimbursement, and provider utilization patterns.
• May serve as a liaison with internal and external business partners.
• Collaborates with internal and external business partners to determine root cause and solve for appropriate resolution.

Minimum Requirements

• High school diploma or GED and a minimum of 6 years of claims research and/or issue resolution or analysis of reimbursement methodologies within the health care industry which would include internal and external customer service experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences

• Claims knowledge experience preferred.
• WGS / CIW experience preferred.
• Excel and reporting knowledge experience preferred.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: CLM > Provider Support

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.