Advisor Business Analyst - Claims Configuration

We need to output HTML fragment with sections: h3 headings for sections present: About the role? The posting includes summary, responsibilities, requirements, qualifications, skills, benefits, pay, schedule. We need to include only sections with real content. We need to parse the posting. First paragraph: "Great companies need great teams..." is generic marketing; maybe part of "About the role"? Could be considered "About the role" content. Then "Summary As an Advisor Business Analyst - Claims Configuration at Gainwell, you will provide senior functional and technical expertise..." That's summary. Then sections: "Your role in our mission Claims Configuration Leadership" etc. Actually they have headings: "Claims Configuration Leadership", "Client and Cross-Functional Engagement", "Configuration Analysis and Solution Design", "Data Analysis, Root Cause Analysis, and Production Support". Those are responsibilities. Then "What We're Looking For" includes required skills and additional preferred skills. Then "What Sets You Apart" includes more qualifications. Then "What You Should Expect In This Role" includes remote options, etc. Then benefits: "All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies..." Pay: "The pay range for this position is $92,900.00 - $132,700.00 per year..." Schedule: Not explicitly given; maybe "Fully remote options from most U.S. locations and territories." That's location, not schedule. No explicit schedule like full-time, part-time. Might not include schedule section. We need to avoid boilerplate: EEO, etc. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. Also remove lines about deadline, video camera requirements, etc? Those are application instructions? The instruction says remove application instructions. So we should remove lines about deadline, video camera usage, quiet location, stable internet, do not use AI tools, etc. Also remove "Please ensure you join all screenings..." etc. Also remove "The deadline to submit applications for this posting is September 24, 2026". Also remove "Put your passion to work at Gainwell..." maybe that's marketing but could stay? It's somewhat generic but maybe keep as part of About the role? Might be considered boilerplate? It's not EEO but still promotional. The instruction: remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. The "Put your passion to work..." is not those; could stay. But we need to preserve all substantive information. So we keep description of role, responsibilities, requirements, qualifications, benefits, pay. We need to use

for section headings: e.g., About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to decide which headings to use. We have content for About the role (intro + summary). Responsibilities (the four sub-sections). Requirements (maybe "What We're Looking For" required skills). Qualifications (maybe "What Sets You Apart" plus education). Skills (maybe combine required and preferred skills? But we already have Requirements for required skills; Skills could be preferred? However instruction: prefer a few substantive sections over many thin ones. Could combine Requirements and Skills into one? But they said use headings for those categories if content exists. We have required skills and preferred skills; we could put both under Requirements (or Skills). But we need to follow instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can include those headings if we have content. We have content for About the role (intro + summary). Responsibilities (the four sections). Requirements (required skills). Qualifications (education + maybe "What Sets You Apart"?). Skills (preferred skills). Benefits (vacation, 401k, health, educational assistance, academies). Pay (range). Schedule: not present, so omit. We must not repeat job title as heading. Good. We need to output only HTML fragment, no /, no markdown. We'll produce something like:

About the role

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development. Summary As an Advisor Business Analyst - Claims Configuration at Gainwell, you will provide senior functional and technical expertise for Medicaid claims configuration within a Maintenance & Operations environment. You will translate client requirements, Medicaid policy, operational needs, and claims-processing outcomes into scalable QNXT configuration solutions while leading a team of Configuration Business Analysts. This role requires deep hands-on QNXT configuration expertise, advanced SQL and relational database knowledge, and the ability to independently investigate complex claims issues, identify root cause, determine corrective solutions, and clearly communicate recommendations to clients, vendors, and internal cross-functional teams.

Responsibilities

• Claims Configuration Leadership – Lead, mentor, and provide day-to-day technical direction to a team of Claims Configuration Business Analysts. Serve as the senior configuration subject matter expert and trusted advisor for assigned CEF Claims M&O accounts. Review configuration analysis, solution designs, implementation plans, and validation results for quality, accuracy, and downstream impact. Establish consistent configuration practices, documentation standards, peer-review controls, and knowledge-transfer processes.
• Client and Cross-Functional Engagement – Interact directly with clients, vendors, and internal business, product, development, testing, operations, finance, provider, member, and encounter teams. Lead requirements discussions, configuration reviews, issue-resolution sessions, defect triage, solution walkthroughs, and operational governance discussions. Translate complex technical findings into clear business impacts, options, risks, and recommendations for stakeholders and leadership. Own assigned issues and enhancements from intake and analysis through implementation, validation, communication, and closure.
• Configuration Analysis and Solution Design – Configure and support QNXT claims solutions across contracts, benefits, fee schedules, payment methodologies, capitation, business rules, claims adjudication logic, X12 transaction data requirements, and CARC/RARC processing. Translate Medicaid policy, contractual requirements, and operational needs into configuration specifications, business rules, design artifacts, and acceptance criteria. Assess the full impact of proposed changes across claims adjudication, pricing, benefits, provider reimbursement, encounters, remittance, financial processing, reporting, and downstream integrations. Determine whether an issue is caused by configuration, data, policy interpretation, user processing, interface behavior, product functionality, or another upstream or downstream dependency.
• Data Analysis, Root Cause Analysis, and Production Support – Write and execute complex SQL queries to analyze claims, claim lines, provider affiliations, contracts, benefits, pricing, member eligibility, edits, accumulators, encounters, and financial data. Use relational database schemas and data relationships to trace system behavior and validate claims-processing outcomes. Perform claim-level and population-level root cause analysis for denials, pends, unexpected edits, underpayments, overpayments, duplicate conditions, encounter rejections, and other processing anomalies. Quantify impacted claims and populations, document evidence, compare expected and actual results, and recommend sustainable corrective actions. Support production incidents, client inquiries, audit requests, configuration defects, data fixes, and ad hoc reporting needs. Validate configuration changes through targeted data analysis, claims testing, regression review, and post-implementation monitoring.

Requirements

• 9+ years of hands‑on, highly proficient QNXT configuration experience, with demonstrated depth in contracts, benefits, fee schedules and multiple payment methodologies, capitation, rules, successful data points for X12 transactions, and CARC/RARC processing.
• Thorough understanding of relational database concepts, healthcare data models, schemas, keys, and data relationships.
• Demonstrated competency writing complex SQL queries for claims analysis, validation, troubleshooting, root cause analysis, and reporting.

Skills

• Strong knowledge of Medicaid claims processing, claims adjudication, provider reimbursement, benefit administration, edits, pricing, and encounter processing.
• Experience analyzing X12 healthcare transactions, including 837 and 835 transaction data and associated remittance adjustment reason codes.
• Proven ability to independently analyze complex claim scenarios, identify root cause, assess impact, and develop actionable business and configuration solutions.
• Experience leading or mentoring Configuration Business Analysts and reviewing technical or functional work products.
• Strong client‑facing communication, facilitation, presentation, documentation, and stakeholder‑management skills.
• Experience working within SDLC, Agile delivery, testing, release management, and production‑support environments.

Qualifications

• Bachelor’s degree in Computer Science, Information Systems, Health Informatics, Business Administration, or a related field, or an equivalent combination of education and relevant experience.
• Experience supporting Medicaid claims configuration in a multi‑account CEF Maintenance & Operations environment.
• Deep expertise in provider contracts, fee schedules, alternative payment methodologies, capitation, benefits, edits, and claims rules.
• Experience with operational monitoring, trend analysis, claims inventory analysis, first‑pass outcomes, denials, and reprocessing impacts.
• Knowledge of CMS guidance, state Medicaid policy, MITA, encounter processing, financial reconciliation, and compliance considerations.
• Experience with IT service management and work‑tracking tools such as ServiceNow, Jira, or similar platforms.
• Ability to balance client priorities, production risk, operational urgency, and long‑term configuration sustainability.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies.

Pay

The pay range for this position is $92,900.00 - $132,700.00 per year (base pay may vary depending on geographic region, internal equity, job‑related knowledge, skills, and experience).

We need to ensure we didn't include any boilerplate like EEO, etc. We removed those. Also removed application instructions like deadline, video camera, quiet location, etc. Also removed lines about "Put your passion to work at Gainwell..." we kept some of that in About the role? Actually we included the initial marketing sentences but not the later "Put your passion to work at Gainwell..." which is somewhat promotional but maybe okay. However we might consider removing that as it's not substantive? It's more marketing but could be considered part of About the role. The instruction: preserve ALL substantive information; do NOT invent or summarize away detail. The "Put your passion to work at Gainwell..." is somewhat generic but still part of posting. It's not boilerplate like EEO. It's not duplicated. I'd keep it maybe in About the role paragraph. But we already have a long About the role paragraph; we could add that sentence at end. However we already have a lot; we could incorporate. Let's add after the summary: "Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development." But we already said similar earlier. Might be duplicate. Safer to keep original intro sentences and not add that. We also need to ensure we didn't include any