Payment Integrity Business Analyst III

Elevance Health • Norfolk, VA

3h • Hybrid

About The Position

Payment Integrity Business Analyst III Hybrid : 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 Payment Integrity Business Analyst III is responsible for reviewing and analyzing payment integrity recovery requests submitted by industry partners. The analyst will assess the validity of each recovery request, determine if recovery is appropriate, and identify potential opportunities for new recovery leads. This role demonstrates a strong understanding of claims processing, coding standards, and analytical problem-solving to ensure accurate and efficient resolution of recovery reviews. Responsible for serving as the liaison between the business and IT in translating complex business needs into application process. How you will make an impact: Analyzes complex end user needs to determine optimal means of meeting those needs. Determines specific business application software requirements to address complex business needs. Develops project plans and identifies and coordinates resources, involving those outside the unit. Works with programming staff to ensure requirements will be incorporated into system design and testing. Acts as a resource to users of the software to address questions/issues. May provide direction and guidance to team members and serves as an expert for the team. Review and evaluate payment integrity recovery requests from external partners to determine validity and appropriateness. Analyze claim data to confirm recovery eligibility using applicable CPT, HCPCS, and ICD-10 codes. Utilize systems such as Facets and Macess to research claims, validate overpayments, and document findings. Apply claims processing knowledge to identify patterns or issues that may lead to new recovery opportunities. Leverage external and internal resources such as the CMS website, State Medicaid websites, and the Knowledge Library to validate recovery requests and ensure regulatory accuracy. Collaborate with internal teams to clarify claim details and ensure accurate communication with partners. Prepare and maintain detailed documentation supporting recovery decisions. Provide recommendations for process improvement and assist with the implementation of corrective actions. Ensure compliance with all internal policies, regulatory requirements, and partner agreements.

Requirements

• Requires a BA/BS and minimum of 5 years business analysis experience; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

• 2–4 years of experience in healthcare claims analysis, payment integrity, claims recovery functions or related field strongly preferred.
• 3-5 years claims adjusting experience.
• Proficient in Facets, Macess, and Microsoft Office Suite (Excel, Word, Outlook) preferred.
• Working knowledge of CPT, HCPCS, and ICD-10 coding, medical claims processing workflows and systems preferred.
• Experience demonstrating analytical, critical thinking, and problem-solving skills preferred.
• Prior experience identifying or developing new recovery lead preferred.
• Experience with data analysis or query tools (e.g., SQL, Tableau, or similar) preferred.
• Experience with strong attention to detail and ability to manage multiple tasks in a fast-paced environment preferred.
• Effective verbal and written communication skills preferred.
• Experience in daily performance metrics and turnaround expectations environment preferred.

Responsibilities

• Analyzes complex end user needs to determine optimal means of meeting those needs.
• Determines specific business application software requirements to address complex business needs.
• Develops project plans and identifies and coordinates resources, involving those outside the unit.
• Works with programming staff to ensure requirements will be incorporated into system design and testing.
• Acts as a resource to users of the software to address questions/issues.
• May provide direction and guidance to team members and serves as an expert for the team.
• Review and evaluate payment integrity recovery requests from external partners to determine validity and appropriateness.
• Analyze claim data to confirm recovery eligibility using applicable CPT, HCPCS, and ICD-10 codes.
• Utilize systems such as Facets and Macess to research claims, validate overpayments, and document findings.
• Apply claims processing knowledge to identify patterns or issues that may lead to new recovery opportunities.
• Leverage external and internal resources such as the CMS website, State Medicaid websites, and the Knowledge Library to validate recovery requests and ensure regulatory accuracy.
• Collaborate with internal teams to clarify claim details and ensure accurate communication with partners.
• Prepare and maintain detailed documentation supporting recovery decisions.
• Provide recommendations for process improvement and assist with the implementation of corrective actions.
• Ensure compliance with all internal policies, regulatory requirements, and partner agreements.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees