Provider Outreach Business Analyst II

Elevance Health•Norfolk, VA

3d•Hybrid

About The Position

The Provider Outreach Business Analyst II is responsible for conducting outbound calls to healthcare providers to verify the accuracy of billed services and ensure claims were submitted and processed appropriately. 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 requires strong attention to detail, foundational claims knowledge, and the ability to follow established procedures to determine the validity of claims prior to initiating contact with providers.

Requirements

Requires a BA/BS and minimum of 3 years related 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, or related field strongly.
Proficient in Facets, Macess, and Microsoft Office Suite (Excel, Word, Outlook).
Experience in medical claims processing workflows and systems.
Experience in payment integrity or claims recovery functions within a health insurance or managed care environment.
Prior experience identifying or developing new recovery leads.
Familiarity with data analysis or query tools (e.g., SQL, Tableau, or similar).

Responsibilities

Conduct outbound provider calls to confirm that services were rendered, and that the provider was expecting payment.
Review claim details to determine claim validity before initiating outreach, ensuring all required information is accurate and complete.
Meet or exceed daily outbound call attempt requirements as established by departmental performance metrics.
Maintain a QA (Quality Assurance) score of 95% or higher, demonstrating adherence to process, accuracy in documentation, and professionalism in communication.
Meet all Service Level Agreement (SLA) requirements related to outreach, documentation, and productivity.
Provide excellent customer service when interacting with providers, addressing questions politely and professionally.
Follow Desk Level Procedures (DLPs), workflows, and operational guidelines to ensure consistency and compliance in all outreach activities.
Accurately document call outcomes and follow-up activities in required systems.
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.
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.