Business Consultant - Payment Integrity Datamining

Elevance Health•Atlanta, IN

8h•Hybrid

About The Position

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending. The Business Consultant will be responsible for translating moderately complex and varied business needs into application software requirements. The role possesses full technical knowledge of most phases of systems and business analysis and is able to consider the business implications of the application of technology to current and future business environments. Operating at a strategic level, this role serves as a “Chief of Staff” for management, providing support in strategic planning and overseeing cross-departmental initiatives to resolve multifaceted business challenges. This role requires strong Quality Assurance and process governance to ensure high standards in processes and outcomes are consistently maintained. The Consultant mentors Business Analysts and Leads, supporting growth and capability in complex problem-solving. The Consultant is tasked with managing very high-complexity concepts/tasks, validating work products prior to reassignment. Responsibilities also include ensuring that Desk Level Procedures (DLPs) are accurate, updated, and consistently followed. In collaboration with managers, the Consultant assesses staff readiness, operational capacity, and market conditions to drive informed decision-making and overall operational excellence.

Requirements

Requires a BA/BS and minimum of 8 years business analysis experience, which should include analysis and project management; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

Demonstrated strategic leadership experience, including the ability to support senior management in cross-departmental initiatives, strategic planning, and the resolution of complex, multifaceted business challenges
Proven capability to provide chief-of-staff–level support, synthesizing information, anticipating needs, and driving clarity and alignment across diverse stakeholder groups
Expertise in Quality Assurance and process governance, ensuring adherence to operational standards, validating high-complexity work products, and safeguarding accuracy and compliance across workflows
Experience managing and maintaining Desk Level Procedures (DLPs) (or equivalent operational documentation), ensuring content is updated, accurate, and consistently followed
Demonstrated mentorship and leadership skills, with experience developing analysts or team leads, enhancing analytical rigor, and strengthening problem-solving capability within teams
Strong organizational insight with the ability to assess staff readiness, operational capacity, and market conditions to inform planning, prioritization, and decision-making
Advanced analytical skills, including the ability to review claim data, identify overpayment trends, validate findings, and troubleshoot complex issues
Ability to translate business needs into technical requirements and assess implications of system capabilities on operational and future-state environments
Strong communication and documentation skills, including the ability to draft provider communications, validation instructions, policies, manuals, and other operational guidance
Demonstrated success in stakeholder engagement, effectively collaborating with internal teams/leaders, external partners, and vendors to address workflow inquiries and ensure alignment
High adaptability and learning agility, with the ability to manage multiple priorities, incorporate new tools and processes, and navigate evolving business needs
Self-starter with a proactive mindset, demonstrating ownership of issues, commitment to continuous improvement, and the capacity to drive operational excellence
Familiarity with healthcare payer systems, claim lifecycle, reimbursement methodologies, and basic medical billing guidelines and regulations
Exposure to medical coding systems (ICD, CPT, HCPCS) preferred
Knowledge of systems capabilities and business operations within Payment Integrity or related environments strongly preferred

Responsibilities

Will function at a strategic level, supporting leadership as a chief-of-staff–style advisor; supporting senior management in cross-departmental initiatives, strategic planning, and resolution of complex, multifaceted business challenges; synthesizing information, anticipating needs, and driving alignment across stakeholders
Will ensure quality governance, evaluate high-complexity concepts, mentor, analyze and lead; provide Quality Assurance oversight; validate high-complexity work products for accuracy/compliance; and ensure adherence to operational standards and process governance
May lead teams of analysts assigned to complex projects; assess staff readiness and operational capacity to inform planning/prioritization; and develop analysts/team leads to strengthen analytical rigor and problem-solving
Determines specific business application software requirements to address complex and varied business needs; translate business needs into technical requirements; and assess system capability implications on current and future-state operations
Analyzes and designs solutions to address complex and varied business needs; apply advanced analytics (e.g., reviewing claim data, identifying overpayment trends, validating findings with precision, and troubleshooting complex issues)
Consults with business partners concerning application and implementation of technology; engage stakeholders (internal teams/leaders, external partners, and vendors) to resolve workflow inquiries and ensure alignment
Evaluate and translate business needs with strong organizational insight (market/operational conditions) to inform planning, prioritization, and decision-making
Design business/technology solutions, including payment integrity / payer operations considerations where applicable
Advise partners on system enhancements with high adaptability and learning agility, incorporating new tools/processes and evolving business needs
Validate complex concepts/work products; maintain and ensure adherence to Desk Level Procedures (DLPs) or equivalent operational documentation