Provider Outreach Business Analyst II

• 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 overpayments, 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.

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.

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.

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 and Influenza. 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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.