Provider Outreach Business Analyst II

This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

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.

This position will work an 8-hour from shift 8:00 am - 5:00 pm (ET) Monday to Friday. Additional hours may be necessary based on company needs.

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.

• 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 over payments, 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.

• 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.

• 2–4 years of experience in healthcare claims analysis, payment integrity, or a related field preferred.
• Proficiency with Facets, Macess, and Microsoft Office (Excel, Word, Outlook) preferred.
• Experience with medical claims processing workflows and related systems preferred.
• Experience supporting payment integrity or claims recovery in a health insurance or managed care environment preferred.
• Prior experience identifying or developing new recovery opportunities/leads preferred.
• Familiarity with data analysis and/or query tools (e.g., SQL, Tableau, or similar) preferred.
• Ability to take ownership of assigned tasks, consistently meet productivity goals, maintain high-quality standards, and ensure timely, accurate documentation while adhering to established procedures and Service Level Agreements (SLAs) preferred.
• Strong analytical and critical-thinking skills with the ability to investigate complex healthcare claims, identify discrepancies, evaluate payment integrity recovery opportunities, determine appropriate resolutions, and recommend process improvements preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

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