Provider Escalations Analyst

Elevance Health•Tampa, FL

6d•Remote

About The Position

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. 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.

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.

Nice To Haves

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

Responsibilities

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.