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Claims Analyst III- Overpayment Prevention

2 months ago

PALO ALTO, United States Elevance Health Full time

Claims Analyst III- Overpayment Prevention (Business Analyst III)

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Commercial State PulsePoint locations.

Schedule: In office 1-2 days per week and must work between the hours of 6am-4pm in respective timezone.

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.

Responsible for identifying, analyzing, and validating overpayment prevention opportunities. Determines specific business requirements to address complex business needs. Works with Query Developers to ensure business requirements are incorporated into query design, completes and coordinates UAT testing on claims identified as potential overpayments. Completes all required documentation to support workflow and reporting. Collaborates with the claims validation team to approve concepts for prevention. Will provide direction and guidance to team members.

How you will make an impact:

  • Assessing overpayment opportunities by reviewing low to high-volume claim samples.

  • Obtain, interpret, and apply provider and member contract language, company claims policies, and coding guidelines to support prevention opportunities.

  • Partnering closely with query data analysts to ensure requirements will be incorporated into prepayment algorithm design and testing that will identify potential overpayments.

  • Manage and prioritize work assignments based on business needs.

  • Effectively research leads to identify additional prevention savings opportunities.

  • Identifies and analyzes complex overpayment prevention needs to determine optimal means of meeting those needs.

  • Determines specific business requirements to address complex business needs.

  • Responsible for translating the most highly complex and varied business needs into BRD requirements for query builds and coordinates UAT, involving those outside the unit.

  • Identify process improvement opportunities that result in increased savings.

  • Serve as a liaison between Postpay team, validation team to maximize savings potential.

  • Analyzes and designs solutions to address complex and varied business needs.

  • Consults with business partners concerning processes, procedures, contracts, processing rules, and other system rules to identify overpayments.

  • Consult with business partners concerning the application and implementation of technology.

  • Writes Business Requirement Documents (BRD) and demonstrates experience and ability to perform UAT for medium to high-complexity projects.

  • Provide direction and guidance to analysts and serve as an expert for the team.

Minimum Requirements:

  • Requires a BA/BS and minimum of 5 years business analysis experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

  • 7 years of business analysis experience, which should include analysis, project management, working knowledge of mainframe computer, hardware, and operating systems preferred.

  • In-depth knowledge of WGS Commercial Claims processing or adjustments is strongly preferred.

  • In-depth knowledge of WGS Commercial Pricing Arrangements for any or all 14 Commercial states preferred.

  • Provider Contract and Member Benefit expertise is 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 preferred.

  • Fluent in MS Excel preferred.

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $72,576 to $129,600.

Locations: California; Colorado; Nevada

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

  • The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.