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 initiatives

• Utilize domain expertise to drive the claims module and manage claims processes

• Analyze business requirements, and create and develop documentation

• Ensure adherence to quality processes

• Collaborate with customers and guide teams throughout the entire project lifecycle

• Meet customer expectations and resolve application issues

• Support customers in making implementation decisions

• Work closely with clients and development teams during the development phases

• Conduct milestone-completion demonstrations and track and address feedback

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

• Validate backend data, which includes claim status, payment details, members/providers, and benefit plans

• Validate test scenarios, test plans, and test data

• Review requirements and documentation, producing Requirements Traceability Matrices (RTMs)

• Evaluate existing product functionality against market trends and regulatory requirements for upcoming versions

• Lead and communicate product-feature requirements with technical and architecture teams

• Engage with cross-functional teams

⛳️ Requirements

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

• Strong background in the healthcare sector with a solid understanding of Medicaid and Medicare

• Practical experience in claims processing and adjudication procedures

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

• Previous experience or comprehension of configuring benefits or programs within claims systems across various subsystems

• Capability to execute queries and perform basic system analysis and root-cause analysis (RCA)

• Exceptional written and verbal communication skills

• Ability to manage multiple tasks among internal teams and clients based on priority

• Comprehensive understanding of claims and the claims lifecycle

• Awareness of claim types including professional, dental, institutional, pharmacy, encounters, and capitation

• Knowledge of EDI X12 formats such as 837P/I/D, 835, 834, 270/271, and 276/277

• Familiarity with claims systems like CMdS, GHS, and Facets

• Proficiency in SQL for backend data validation

• Experience with EDI tools for X12 file validation

• Understanding of interface testing and data flows between systems and formats

• Familiarity with tools such as Postman

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

• Competence in reviewing requirements and documentation to create a Requirements Traceability Matrix (RTM)

• Capability to engage with QA/development teams, clients, end users, and business units

• Ability to assess product functionality in light of market trends and regulatory requirements

• Skill in communicating requirements to technical and architecture teams

• Authorization to work in the United States is implied by the US-specific role context

🏝️ Benefits

• Comprehensive health insurance coverage

• Optional dental and vision programs

• Life and disability insurance

• Retirement savings plan

• Paid holidays

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

• Potential eligibility for a bonus or incentive based on business needs

• Reasonable accommodations for applicants with disabilities