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 health care initiatives.

• Oversee the claims module and processes, offering domain expertise.

• Evaluate business requirements.

• Craft and develop documentation while ensuring quality processes and collaborating with clients.

• Function within a team environment, providing guidance throughout the project's entire life cycle.

• Fulfill customer expectations and resolve application issues.

• Support clients with implementation choices.

• Collaborate closely with clients and development teams during the development phases.

• Conduct demonstrations at the completion of milestones and manage feedback.

• Work alongside development, architecture, and design teams to define GUI views and platform specifications.

• Validate test scenarios, plans, and data.

• Evaluate existing product features against market trends and regulatory standards.

• Propel and communicate product feature requirements to technical and architecture teams.

• Partner with cross-functional teams.

⛳️ Requirements

• Extensive experience in the health care domain.

• Strong familiarity with Medicaid and Medicare.

• Practical experience with claims processing and adjudication procedures.

• Proficient in reference codes/data sets necessary for claims adjudication.

• Background or understanding in configuring benefits or programs within claims systems across various subsystems.

• Capability to execute queries and perform basic system analysis and root-cause analysis.

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

• Skill in conducting milestone demonstrations and managing feedback.

• Exceptional written and verbal communication abilities.

• Capacity to juggle tasks between internal teams and clients based on priority.

• Comprehensive understanding of claims and the claims lifecycle, including member, provider, claim submission, adjudication, payment cycle, and reporting.

• Knowledge of various claim types including professional, dental, institutional, pharmacy, encounter, and capitation.

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

• Experience with claims systems like CMdS, GHS, and Facets.

• Proficient in SQL for backend data validation.

• Experience using EDI tools for X12 file validation.

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

• Experience with tools such as Postman.

• At least 8 years of experience in health care, particularly in MMIS.

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

• Competence in reviewing requirements and documentation and creating a Requirements Traceability Matrix.

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

• Capability to assess product functionality in relation to market trends and regulatory requirements.

• Ability to convey requirements to technical and architecture teams.

🏝️ Benefits

• Opportunity for remote work from home.

• Career advancement opportunities.

• 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 for bonuses or incentives based on business needs.