Remote Provider Escalations Specialist

Elevance Health; Tampa (FL); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Elevance Health is seeking a Provider Escalations Analyst to manage PIR escalations across lines of business, analyzing provider payment issues and communicating contracts and medical policies. The role emphasizes collaboration with internal and external partners and rigorous claims analysis.

Responsibilities include remediation of high-dollar claims, contract dispute resolution, and identifying process improvements while ensuring adherence to reimbursement guidelines and policies.

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.
• 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.

Skills

Claims knowledge

Excel proficiency

Education

High school diploma or GED

Tools

Excel

Job description

Elevance Health is seeking a Provider Escalations Analyst to manage PIR escalations across lines of business, analyzing provider payment issues and communicating contracts and medical policies. The role emphasizes collaboration with internal and external partners and rigorous claims analysis.

Responsibilities include remediation of high-dollar claims, contract dispute resolution, and identifying process improvements while ensuring adherence to reimbursement guidelines and policies.