Senior Business Analyst – MMIS Claims Processing

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

📋 Description

• Oversee the requirements gathering, analysis, documentation, and validation processes for MMIS modernization projects, focusing primarily on Claims Processing.

• Organize Joint Application Design (JAD) sessions and collaborative meetings with state stakeholders, business units, technical teams, and vendors.

• Convert intricate business needs into clear, structured, and testable business requirements utilizing established business analysis methodologies.

• Monitor the requirements from the initial scope definition through to refinement, validation, implementation, and testing support.

• Perform current-state versus future-state gap analysis and recommend modernization strategies that align with Commonwealth objectives.

• Ensure traceability of requirements throughout the Software Development Life Cycle (SDLC).

• Assist with defect triage, operational impact analysis, issue resolution, and change management activities.

• Collaborate closely with development and QA teams to ensure that the business intent is accurately realized.

• Lead analysis efforts for the modernization of the MMIS Claims Processing solution, including:

• - Claims intake and submission workflows

• - Claims editing and validation

• - Claims adjudication and pricing

• - Payment processing and financial disposition

• - Denials, suspensions, adjustments, and voids

• - Coordination of Benefits (COB)

• - Third Party Liability (TPL)

• - Managed Care encounter processing

• - Provider reimbursement methodologies

• - Claims lifecycle reporting and operational monitoring

• Analyze and document business requirements for various claim submission channels, including:

• - Provider Web Portal

• - Electronic Data Interchange (EDI)

• - X12 transaction processing

• - Batch file interfaces

• - Clearinghouse integrations

• - System-to-system interfaces

• Develop business requirements that support the processing of standard healthcare transactions, including:

• - 837 Institutional (837I)

• - 837 Professional (837P)

• - 837 Dental (837D)

• - 835 Electronic Remittance Advice

• - 270/271 Eligibility Inquiry & Response

• - 276/277 Claim Status Inquiry & Response

• - Other HIPAA-compliant X12 transactions that support Medicaid operations

• Collaborate with business and technical teams to analyze:

• - Claims editing rules

• - Benefit and policy validation

• - Payment logic

• - Pricing methodologies

• - Provider reimbursement

• - Financial reconciliation

• - Exception handling

• - Operational workflows

• Produce comprehensive Business Requirements Documents (BRDs) that include:

• - Business background and objectives

• - Current-state and future-state business processes

• - Claims workflow analysis

• - Business rules

• - Detailed business requirements

• - Operational impacts and dependencies

• - Assumptions

• - Key decisions

• - Open issues

• - Testing considerations

• - Validation scenarios

• Develop:

• - Process flows

• - Decision trees

• - Use cases

• - Decision tables

• - Data mapping documentation

• - Interface specifications

• - Business rules catalogs

• - Workflow diagrams

• Maintain high standards of documentation quality across all outputs.

• Utilize AI tools and prompt engineering techniques to facilitate requirements generation, business analysis tasks, and documentation creation.

• Create and enhance AI prompts to boost the quality and efficiency of requirements-related outputs.

• Assess AI-generated results for accuracy, completeness, consistency, and business relevance.

• Employ critical thinking and business judgment while applying AI-assisted analysis methods.

• Establish strong working relationships with client stakeholders, project leadership, and cross-functional teams.

• Guide productive discussions and diplomatically question unclear or incomplete requirements when needed.

• Effectively communicate complex business and technical concepts to both technical and non-technical audiences.

• Anticipate downstream impacts, risks, dependencies, financial implications, and operational considerations linked to requirements decisions.

• Work independently as a self-starter while contributing to broader modernization program goals.

⛳️ Requirements

• Extensive experience as a Business Analyst supporting MMIS/MES or Medicaid modernization projects.

• Direct experience in supporting MMIS Claims Processing.

• In-depth understanding of the entire Medicaid claims lifecycle from submission to adjudication, payment, adjustment, and financial reconciliation.

• Experience with claims editing, pricing, adjudication logic, payment methodologies, and business rules.

• Familiarity with HIPAA X12 healthcare transaction standards.

• Experience in supporting electronic claims processing and diverse claim intake channels.

• Strong preference for candidates with CLIENT-SIDE MMIS experience (state agency/business operations perspective) rather than solely vendor-module implementation experience.

• Proven experience in facilitating stakeholder sessions, JAD workshops, and executive-level business discussions.

• Demonstrated ability to produce high-quality BUSINESS requirements (not just functional or technical requirements).

• Deep understanding of:

• - Requirements gathering and validation

• - Business process analysis

• - SDLC methodologies

• - Gap analysis

• - Medicaid claims operations

• - Claims adjudication business rules

• - Healthcare payment processing

• - Medicaid policy-driven systems

• Strong verbal and written communication skills with meticulous attention to detail.

• Ability to navigate ambiguity and function effectively within large-scale enterprise modernization initiatives.

🏝️ Benefits

• Medical / Dental / Vision Insurance – insurance premium assistance provided.

• Additional Insurance (Life, Disability, etc.).

• Paid Time Off.

• 401(k) Retirement Savings Plan & Health Savings Account.

• Various training courses to encourage continuous learning.

• Corporate Wellness Program.