Provider Escalations Analyst Senior

Elevance Health•Indianapolis, IN

3d•Remote

About The Position

The Provider Escalations Analyst Sr 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. This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

Requirements

Requires a high school diploma or GED and a minimum of 8 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.

Nice To Haves

Experience in independent dispute resolution strongly preferred

Responsibilities

Remediate impacted multi claim issues (request and analyze claim impact reports & initiate sweeps), investigate the outcome of claim payment or denial for high visibility provider escalations through the PIR support process or regulatory, legal or presidential escalation channels.
May adjust complex claims for a specific line of business and market, adjust voids, rekey and reopen claims on-line 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 facilitates process improvement projects and coordinates communication processes on medical policy, reimbursement, and provider utilization patterns.
May serve as a liaison and SME with internal and external business partners.
Serve as a mentor and trainer for provider escalation analysts and coordinates UAT testing and other project work.
Collaborates with internal and external business partners to determine root cause and solve for appropriate resolution.