Business Analyst – Claims Configuration

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee, mentor, and provide daily technical guidance to a team of Claims Configuration Business Analysts.

• Act as the senior configuration subject matter expert and reliable advisor for designated CEF Claims Maintenance & Operations accounts.

• Evaluate configuration analysis, solution designs, implementation strategies, and validation outcomes.

• Develop configuration practices, documentation standards, peer-review mechanisms, and knowledge-transfer methods.

• Collaborate with clients, vendors, and internal teams across business, product, development, testing, operations, finance, provider, member, and encounter functions.

• Facilitate requirements discussions, configuration evaluations, issue-resolution meetings, defect triage, solution presentations, and operational governance discussions.

• Convert technical findings into business implications, options, risks, and recommendations.

• Manage issues and enhancements from intake and analysis to implementation, validation, communication, and closure.

• Configure and support QNXT claims solutions regarding contracts, benefits, fee schedules, payment methodologies, capitation, business rules, claims adjudication logic, X12 transaction data requirements, and CARC/RARC processing.

• Interpret Medicaid policy, contractual obligations, and operational requirements into configuration specifications, business rules, design documents, and acceptance criteria.

• Evaluate impacts on claims adjudication, pricing, benefits, provider reimbursement, encounters, remittance, financial processing, reporting, and downstream integrations.

• Identify root causes across configuration, data, policy interpretation, user processing, interfaces, product functionality, and dependencies.

• Write and execute complex SQL queries to analyze claims and associated healthcare data.

• Conduct claim-level and population-level root cause analysis for denials, pends, edits, payment issues, duplicates, encounter rejections, and other anomalies.

• Quantify affected claims and populations, document findings, compare expected and actual outcomes, and suggest corrective measures.

• Assist with production incidents, client inquiries, audits, configuration issues, data corrections, and ad hoc reporting.

• Validate configuration modifications through data analysis, claims testing, regression reviews, and post-implementation monitoring.

• Coordinate production support, priority issue resolution, scheduled releases, and collaboration across multiple client and internal teams.

⛳️ Requirements

• 9+ years of extensive, proficient QNXT configuration experience.

• Proven expertise in contracts, benefits, fee schedules, various payment methodologies, capitation, rules, successful data points for X12 transactions, and CARC/RARC processing.

• Comprehensive understanding of relational database concepts, healthcare data models, schemas, keys, and data relationships.

• Proficient in writing complex SQL queries for claims analysis, validation, troubleshooting, root cause analysis, and reporting.

• Solid knowledge of Medicaid claims processing, claims adjudication, provider reimbursement, benefit administration, edits, pricing, and encounter processing.

• Experience in analyzing X12 healthcare transactions, including 837 and 835 transaction data and related remittance adjustment reason codes.

• Capability to independently analyze intricate claim scenarios, identify root causes, assess impacts, and devise actionable business and configuration solutions.

• Experience in leading or mentoring Configuration Business Analysts and reviewing technical or functional deliverables.

• Strong client-facing communication, facilitation, presentation, documentation, and stakeholder management skills.

• Background in working within SDLC, Agile delivery, testing, release management, and production support environments.

• Bachelor’s degree in Computer Science, Information Systems, Health Informatics, Business Administration, or a related field, or an equivalent combination of education and relevant experience.

• Experience in supporting Medicaid claims configuration in a multi-account CEF Maintenance & Operations environment.

• Knowledge of CMS guidelines, state Medicaid policies, MITA, encounter processing, financial reconciliation, and compliance considerations.

• Familiarity with IT service management and work-tracking tools such as ServiceNow, Jira, or similar platforms.

• Ability to prioritize client needs, production risks, operational urgency, and long-term configuration sustainability.

• Video cameras are required to be used during all interviews and throughout the initial week of orientation.

• A stable internet connection and a quiet environment for screenings, interviews, and meetings are essential.

🏝️ Benefits

• Flexible work arrangements.

• Opportunities for learning and career advancement.

• Generous and flexible vacation policy.

• 401(k) employer contribution.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development programs.

• Equal Opportunity Employer.