Prvdr Escalations Analyst at Elevance Health in Tampa, Florida

Job Description:

Responsible for Provider Issues Resolution (PIR) escalations across all lines of business and is responsible for the resolution of provider payment escalation requests and communication of contracts along with medical and clinical policies. Primary duties include but are not limited to: remediate impacted high dollar multi claim issues (request and analyze 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. Requires a 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.