Senior Business Analyst, Claims Module

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

📋 Description

• Act as the Claims Domain lead for MMIS healthcare projects.

• Lead the claims module and processes while providing domain expertise.

• Analyze business requirements thoroughly.

• Design and produce documentation, ensuring quality processes while collaborating with customers.

• Work collaboratively in a team environment and offer guidance throughout the entire project lifecycle.

• Meet customer expectations and troubleshoot application issues effectively.

• Support customers with implementation decisions.

• Collaborate closely with development, architecture, and design teams to define GUI views and platform requirements.

• Engage with clients and development teams during the various development phases.

• Conduct demonstrations upon milestone completion and manage feedback effectively.

• Validate test scenarios, test plans, and test data.

• Review requirements and documentation, creating Requirements Traceability Matrices.

• Evaluate current product functionality in relation to market trends and regulatory standards.

• Drive and communicate product feature requirements with technical and architecture teams.

⛳️ Requirements

• Extensive healthcare domain experience with solid knowledge of Medicaid and Medicare.

• Practical experience in claims processing and adjudication processes.

• Familiarity with reference code/data sets necessary for claims adjudication.

• Previous experience or understanding of configuring benefits or programs in claims systems across various subsystems.

• Ability to execute queries and perform fundamental system analysis and root-cause analysis.

• Capability to collaborate closely with clients and development teams during development stages.

• Proficiency in conducting milestone demonstrations, tracking feedback, and addressing feedback items.

• Exceptional written and verbal communication skills.

• Ability to multitask between internal teams and clients based on priority assignments.

• Understanding of claims and the claims lifecycle, which includes member, provider, claim submission, adjudication, payment cycle, and reporting.

• Knowledge of various claim types: professional, dental, institutional, pharmacy, encounters, and capitation.

• Familiarity with EDI X12 formats 837P/I/D, 835, 834, 270/271, and 276/277.

• Experience with claims systems such as CMdS, GHS, and Facets.

• Proficient in SQL for backend data validation.

• Experience with EDI tools for validating X12 files.

• Understanding of interface testing and data flows; experience with tools like Postman.

• A minimum of 8+ years of healthcare experience, particularly in the MMIS domain.

• Ability to validate test scenarios, test plans, and test data.

• Capability to review requirements and documentation, creating a Requirements Traceability Matrix (RTM).

• Ability to evaluate product functionality against market trends and regulatory standards.

• Ability to communicate requirements effectively to technical and architecture teams.

• No specific educational credential is mentioned.

🏝️ Benefits

• Option to work remotely from home.

• Opportunities for career advancement.

• Coverage for health insurance.

• Voluntary programs for dental and vision insurance.

• Life and disability insurance provided.

• Retirement savings plan available.

• Paid holidays.

• Paid time off (PTO) or vacation and/or sick leave.

• Potential for bonuses or incentives based on business needs.