Provider Escalations Specialist

Elevance Health; United States; Hybrid; USD 70,000 - 90,000; Full time

Job summary

Elevance Health seeks a Provider Escalations Analyst to manage PIR escalations across all lines of business and resolve provider payment escalation requests while communicating contracts and medical policies. The role supports virtual full-time work with in-person training and occasional alternate locations within commuting distance.

Hybrid work policy applies; candidates outside commuting distance may be considered only with an accommodation.

Qualifications

• 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.
• Experience with claims knowledge and WGS/CIW is preferred.
• Proficiency in Excel and reporting tools is preferred.

Responsibilities

• Remediate high dollar multi-claim issues by analyzing and adjusting claim impact reports and initiating sweeps.
• Investigate outcome of claim payments or denials for provider escalations through the PIR process.
• May adjust claims for specific lines of business within guidelines to ensure proper adjudication.
• Interpret benefits, policies, provider contracts, and adjudication of claims.
• Identify barriers and participate in process improvement projects related to medical policy, reimbursement, and provider utilization.
• Serve as a liaison with internal and external business partners and collaborate to determine root cause and resolution.

Skills

Claims knowledge

WGS/CIW experience

Excel reporting

Education

High school diploma or GED

Job description

Elevance Health seeks a Provider Escalations Analyst to manage PIR escalations across all lines of business and resolve provider payment escalation requests while communicating contracts and medical policies. The role supports virtual full-time work with in-person training and occasional alternate locations within commuting distance.

Hybrid work policy applies; candidates outside commuting distance may be considered only with an accommodation.