Healthcare Claims Business Analyst – SME

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

📋 Description

• Act as the internal and external subject matter expert on healthcare claims operations, EDI transaction standards, and payer-side adjudication logic.

• Convert client payer workflows and claims processing needs into business and functional specifications.

• Provide guidance to clients on claims intake, adjudication rules, coordination of benefits, appeals and grievances, and remittance processing.

• Recognize discrepancies between client legacy processes and Incedo capabilities and escalate as necessary.

• Assist with claims data migration strategies, crosswalks for legacy systems, and validation of historical claims data.

• Lead requirements gathering sessions, workflow mapping, and gap analysis during the onboarding of clients.

• Create BRDs, functional specifications, data mapping templates, and EDI companion guides.

• Coordinate comprehensive X12 transaction testing with client EDI teams and clearinghouse partners.

• Facilitate user acceptance testing for various claims processing scenarios.

• Document client-specific configurations, workflow decisions, and exceptional cases.

• Collaborate with Engagement Managers and Technical Leads to monitor milestones, escalate risks, and manage expectations.

• Stay informed about CMS regulations, HIPAA standards, and state Medicaid requirements.

• Advise clients on CMS-0057-F, timelines for the No Surprises Act, and state prompt pay laws.

• Support the configuration of Medicare Advantage, Medicaid managed care, and CHIP encounter data submissions.

• Keep track of updates in X12, ICD/CPT/HCPCS, and CMS NCCI that may impact configurations.

• Develop training materials, job aids, and onboarding playbooks.

• Mentor junior staff involved in implementations.

• Work together with Product and Engineering teams on enhancement requests and market requirements.

• Share claims best practices and lessons learned in the Implementation Playbook.

⛳️ Requirements

• Bachelor’s Degree in Health Information Management, Healthcare Administration, Computer Science, Business, or equivalent experience.

• At least 5 years of experience in a healthcare payer environment.

• Practical experience with HIPAA X12 EDI transactions including 834, 837P/I/D, 835, 270/271, 275, 276/277, and 278.

• Familiarity with claims adjudication systems, relationships with clearinghouses, and onboarding processes for payer-side EDI trading partners.

• Knowledge of ICD-10, CPT, HCPCS Level II, revenue codes, and NCCI edits.

• Experience in supporting software implementations or system migrations within a healthcare payer context.

• Willingness to travel to client locations as required, estimated up to 20%.

• This position does not qualify for sponsorship.

• Comprehensive understanding of the complete payer claims lifecycle.

• Proficient in HIPAA ASC X12 transaction sets with the ability to read, interpret, and troubleshoot raw EDI files.

• Capable of conducting structured discovery sessions and translating requirements into technical specifications.

• Excellent written communication skills for BRDs, data dictionaries, and process flow diagrams.

• Ability to handle multiple concurrent client engagements with minimal oversight.

• Skilled in coordinating with internal teams and external stakeholders.

• Strong analytical skills and attention to detail when validating EDI data and adjudication results.

• Familiarity with relational databases and SQL.

• Preferred: Experience in Medicare Advantage or Medicaid managed care claims operations.

• Preferred: Knowledge of CMS-0057-F electronic prior authorization.

• Preferred: Understanding of No Surprises Act requirements.

• Preferred: Experience with utilization management or care management platforms.

• Preferred: Certification such as CPHQ, RHIT, RHIA, or equivalent in healthcare informatics.

• Preferred: PMP certification.

• Preferred: SQL skills for claims data validation and ad hoc reporting.

• Preferred: Experience with healthcare IT vendors or SaaS implementations.

🏝️ Benefits

• Competitive compensation plan.

• Eligible for annual bonuses.

• Health, Dental, and Vision insurance plans.

• Weekly yoga classes in the office.

• Monthly lunches provided.

• Access to fresh fruit and dry snacks daily.

• Life insurance coverage.

• Short-term and long-term disability benefits.

• 401(k) retirement savings plan.

• Paid holidays and vacation time.

• On-site gym facilities.

• Opportunities for community volunteering.

• Flexible remote work environment.

• Reasonable accommodations available for individuals with disabilities.