Business Consultant - Commercial Claims Data Mining

Business Consultant - Commercial Claims Data Mining

Hybrid:
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.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical‑expense spending.

Schedule:
Monday - Friday

The Business Consultant is responsible for translating moderately complex and varied business needs into application software requirements. Possesses full technical knowledge of most phases of systems and business analysis and is able to consider the business implications of the application of technology to current and future business environments.

• May lead teams of analysts assigned to complex projects.
• Analyze, design and determines specific business requirements, works directly with Query Developers to ensure requirements will be incorporated into recovery query design and validation.
• Consults with business partners concerning application and implementation of technology.
• Consults with business partners concerning processes, procedures, contracts, processing rules and other system rules to create queries that identify Cost of Care and Total Program Savings opportunities.
• Obtains, interprets and applies provider and member contract language to support the creation of Business Requirement Documents (BRD) that contribute to Cost of Care and Total Program Savings.
• Writes Business Requirement Documents (BRD) and able to perform Concept Verification for low to high complexity projects.
• Engage key stakeholders (RAC, Vendors, Provider, COC leads, etc.) and facilitate meetings (agenda, objectives, outcomes, etc.).
• Coaches and mentors team members.
• Effectively communicate defects and/or enhancements to business and/or IT partners.
• Serves as POC on New Concepts as they are expanded across the Enterprise.
• Participate in and or lead special projects.

• BA/BS and minimum of 8 years business analysis experience, which should include analysis and project management; or any combination of education and experience which would provide an equivalent background.

• Demonstrated strong analytical and problem‑solving skills with research‑oriented approach.
• Ability to manage multiple projects in various stages and complexity levels to completion.
• Demonstrated meeting facilitation skills.
• Demonstrated ability to support Commercial States
• Knowledge of systems capabilities and business operations is strongly preferred.
• In‑depth knowledge of WGS Commercial Claims processing or adjustments is required.
• In‑depth knowledge of WGS Pricing Arrangements is preferred.
• Provider Contract and Member Benefit expertise – highly preferred.
• Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.
• Project management, ability to manage multiple projects in various stages to completion.
• Fluent in MS Excel, Word and Power Point.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a 'sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling…