Provider Escalations Analyst

Elevance Health; Nashville (TN); On-site; USD 65,000 - 90,000; Full time

Job summary

Elevance Health in Nashville, TN is seeking a Provider Escalations Analyst to manage PIR escalations across lines of business, resolving provider payment issues and communicating contracts and medical policies.

You will collaborate with internal and external partners, analyze claims, identify root causes, and drive process improvements while adhering to policy and contract terms. This role offers hybrid/virtual work options with periodic in-person onboarding and training.

Qualifications

• High school diploma or GED; 6+ years in claims research and/or issue resolution or reimbursement analysis in healthcare.
• Experience with claims systems and understanding of provider contracts and policies is preferred.
• Strong Excel and reporting tools knowledge.

Responsibilities

• Remediate high-dollar multi-claim issues, analyze and adjust claim impact reports, and initiate sweeps.
• Investigate claim payment or denial outcomes for provider escalations per PIR processes.
• Adjust claims for specific lines of business within guidelines to ensure proper adjudication and comprehension of contracts and policies.
• Identify barriers and participate in process improvement projects related to medical policy, reimbursement, and provider utilization patterns.
• Collaborate with internal and external partners to determine root causes and drive final resolution.

Skills

Claims research

Issue resolution

Customer service

Excel

Reporting

Education

High school diploma or GED

Tools

Microsoft Excel

Reporting tools

Job description

Provider Escalations Analyst

Virtual: 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.

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.

How you will make an impact:

• 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.

Minimum 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.

Preferred Skills, Capabilities and Experiences

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

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.xhtml?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/).