Remote Provider Escalations Specialist

Elevance Health; Nashville (TN); Hybrid; 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

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.