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.

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.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.