Payment Integrity Business Analyst III

Norfolk, MA - USA

Monthly Salary: Not Disclosed

Posted on: Yesterday

Vacancies: 1 Vacancy

Job Summary

Anticipated End Date:

Position Title:

Payment Integrity Business Analyst III

Job Description:

Payment Integrity Business Analyst III

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.

The Payment Integrity Business Analyst III is responsible for reviewing and analyzing payment integrity recovery requests submitted by industry partners. The analyst will assess the validity of each recovery request determine if recovery is appropriate and identify potential opportunities for new recovery leads. This role demonstrates a strong understanding of claims processing coding standards and analytical problem-solving to ensure accurate and efficient resolution of recovery reviews. Responsible for serving as the liaison between the business and IT in translating complex business needs into application process.

How you will make an impact:

Analyzes complex end user needs to determine optimal means of meeting those needs.
Determines specific business application software requirements to address complex business needs.
Develops project plans and identifies and coordinates resources involving those outside the unit.
Works with programming staff to ensure requirements will be incorporated into system design and testing.
Acts as a resource to users of the software to address questions/issues.
May provide direction and guidance to team members and serves as an expert for the team.
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.
Apply claims processing knowledge to identify patterns or issues that may lead to new recovery opportunities.
Leverage external and internal resources such as the CMS website State Medicaid websites and the Knowledge Library to validate recovery requests and ensure regulatory accuracy.
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.

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:

24 years of experience in healthcare claims analysis payment integrity claims recovery functions or related field strongly preferred.
3-5 years claims adjusting experience.
Proficient in Facets Macess and Microsoft Office Suite (Excel Word Outlook) preferred.
Working knowledge of CPT HCPCS and ICD-10 coding medical claims processing workflows and systems preferred.
Experience demonstrating analytical critical thinking and problem-solving skills preferred.
Prior experience identifying or developing new recovery lead preferred.
Experience with data analysis or query tools (e.g. SQL Tableau or similar) preferred.
Experience with strong attention to detail and ability to manage multiple tasks in a fast-paced environment preferred.
Effective verbal and written communication skills preferred.
Experience in daily performance metrics and turnaround expectations environment preferred.

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 instructions. Associates in these jobs must follow the specific policies procedures guidelines etc. as stated by the Government Business Division in which they are employed.

Job Level:

Non-Management Exempt

Workshift:

Job Family:

BSP > Business Support

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.

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 may contact for assistance. 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.

Required Experience:

Anticipated End Date:Position Title:Payment Integrity Business Analyst IIIJob Description:Payment Integrity Business Analyst III 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 ...

Anticipated End Date:

Position Title:

Payment Integrity Business Analyst III

Job Description:

Payment Integrity Business Analyst III

How you will make an impact:

Analyzes complex end user needs to determine optimal means of meeting those needs.
Determines specific business application software requirements to address complex business needs.
Develops project plans and identifies and coordinates resources involving those outside the unit.
Works with programming staff to ensure requirements will be incorporated into system design and testing.
Acts as a resource to users of the software to address questions/issues.
May provide direction and guidance to team members and serves as an expert for the team.
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.
Apply claims processing knowledge to identify patterns or issues that may lead to new recovery opportunities.
Leverage external and internal resources such as the CMS website State Medicaid websites and the Knowledge Library to validate recovery requests and ensure regulatory accuracy.
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.

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:

24 years of experience in healthcare claims analysis payment integrity claims recovery functions or related field strongly preferred.
3-5 years claims adjusting experience.
Proficient in Facets Macess and Microsoft Office Suite (Excel Word Outlook) preferred.
Working knowledge of CPT HCPCS and ICD-10 coding medical claims processing workflows and systems preferred.
Experience demonstrating analytical critical thinking and problem-solving skills preferred.
Prior experience identifying or developing new recovery lead preferred.
Experience with data analysis or query tools (e.g. SQL Tableau or similar) preferred.
Experience with strong attention to detail and ability to manage multiple tasks in a fast-paced environment preferred.
Effective verbal and written communication skills preferred.
Experience in daily performance metrics and turnaround expectations environment preferred.