Business Consultant - Payment Integrity Datamining

Anticipated End Date:

2026-05-01

Position Title:

Business Consultant - Payment Integrity Datamining

Job Description:

Business Consultant - Payment Integrity Datamining

Location: 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. Alternate locations may be considered if candidates reside within 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.

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together.

Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Business Consultant will be responsible for translating moderately complex and varied business needs into application software requirements. The role possesses full technical knowledge of most phases of systems and business analysis and is able to consider the business implications of the application of technology to current and future business environments.

Operating at a strategic level, this role serves as a “Chief of Staff” for management, providing support in strategic planning and overseeing cross-departmental initiatives to resolve multifaceted business challenges. This role requires strong Quality Assurance and process governance to ensure high standards in processes and outcomes are consistently maintained. The Consultant mentors Business Analysts and Leads, supporting growth and capability in complex problem-solving. The Consultant is tasked with managing very high-complexity concepts/tasks, validating work products prior to reassignment. Responsibilities also include ensuring that Desk Level Procedures (DLPs) are accurate, updated, and consistently followed. In collaboration with managers, the Consultant assesses staff readiness, operational capacity, and market conditions to drive informed decision-making and overall operational excellence.

How you will make an impact:

• Will function at a strategic level, supporting leadership as a chief-of-staff–style advisor; supporting senior management in cross-departmental initiatives, strategic planning, and resolution of complex, multifaceted business challenges; synthesizing information, anticipating needs, and driving alignment across stakeholders
• Will ensure quality governance, evaluate high-complexity concepts, mentor, analyze and lead; provide Quality Assurance oversight; validate high-complexity work products for accuracy/compliance; and ensure adherence to operational standards and process governance
• May lead teams of analysts assigned to complex projects; assess staff readiness and operational capacity to inform planning/prioritization; and develop analysts/team leads to strengthen analytical rigor and problem-solving
• Determines specific business application software requirements to address complex and varied business needs; translate business needs into technical requirements; and assess system capability implications on current and future-state operations
• Analyzes and designs solutions to address complex and varied business needs; apply advanced analytics (e.g., reviewing claim data, identifying overpayment trends, validating findings with precision, and troubleshooting complex issues)
• Consults with business partners concerning application and implementation of technology; engage stakeholders (internal teams/leaders, external partners, and vendors) to resolve workflow inquiries and ensure alignment
• Evaluate and translate business needs with strong organizational insight (market/operational conditions) to inform planning, prioritization, and decision-making
• Design business/technology solutions, including payment integrity / payer operations considerations where applicable
• Advise partners on system enhancements with high adaptability and learning agility, incorporating new tools/processes and evolving business needs
• Validate complex concepts/work products; maintain and ensure adherence to Desk Level Procedures (DLPs) or equivalent operational documentation

Minimum Requirements:

• Requires a BA/BS and minimum of 8 years business analysis experience, which should include analysis and project management; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Demonstrated strategic leadership experience, including the ability to support senior management in cross-departmental initiatives, strategic planning, and the resolution of complex, multifaceted business challenges
• Proven capability to provide chief-of-staff–level support, synthesizing information, anticipating needs, and driving clarity and alignment across diverse stakeholder groups
• Expertise in Quality Assurance and process governance, ensuring adherence to operational standards, validating high-complexity work products, and safeguarding accuracy and compliance across workflows
• Experience managing and maintaining Desk Level Procedures (DLPs) (or equivalent operational documentation), ensuring content is updated, accurate, and consistently followed
• Demonstrated mentorship and leadership skills, with experience developing analysts or team leads, enhancing analytical rigor, and strengthening problem-solving capability within teams
• Strong organizational insight with the ability to assess staff readiness, operational capacity, and market conditions to inform planning, prioritization, and decision-making
• Advanced analytical skills, including the ability to review claim data, identify overpayment trends, validate findings, and troubleshoot complex issues
• Ability to translate business needs into technical requirements and assess implications of system capabilities on operational and future-state environments
• Strong communication and documentation skills, including the ability to draft provider communications, validation instructions, policies, manuals, and other operational guidance
• Demonstrated success in stakeholder engagement, effectively collaborating with internal teams/leaders, external partners, and vendors to address workflow inquiries and ensure alignment
• High adaptability and learning agility, with the ability to manage multiple priorities, incorporate new tools and processes, and navigate evolving business needs
• Self-starter with a proactive mindset, demonstrating ownership of issues, commitment to continuous improvement, and the capacity to drive operational excellence
• Familiarity with healthcare payer systems, claim lifecycle, reimbursement methodologies, and basic medical billing guidelines and regulations
• Exposure to medical coding systems (ICD, CPT, HCPCS) preferred
• Knowledge of systems capabilities and business operations within Payment Integrity or related environments strongly preferred

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

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 elevancehealthjobssupport@elevancehealth.com 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.

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.