Claims Module Senior Business Analyst

About The Role

This individual will play the role of Claims Domain lead for MMIS health care projects.

Responsibilities

• Drive the claims module and process and provide domain knowledge
• Perform analysis of business requirements
• Design and develop documentation and ensure quality process while coordinating with customers
• Work in a team environment and provide guidance throughout the entire life cycle
• Responsible for meeting customer expectations and troubleshooting problems in the application
• Aid customers in implementation decisions

Requirements

• Strong health care domain experience and good knowledge of Medicaid and Medicare
• Hands-on experience on claims processing and Adjudication processes
• Good experience in Reference code/data sets required in Claims adjudication
• Prior experience or understanding in configuring benefits or programs in claims system across various sub-systems
• Ability to run queries and perform basic system analysis, RCA etc.
• Work closely with the client and development team during the stages of development, and conduct demos at completion of milestones, track and close feedback from such demos
• Excellent written and spoken communication skills
• Ability to multitask between internal team and clients based on priority tasks
• Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product
• In depth understanding of Claims and Claims lifecycle: Member, Provider, Claim submission – Paper and EDI X12, Adjudication, Payment Cycle (Finance), Reporting Claim Types: Professional, Dental, Institutional, Pharmacy, Encounters and Capitation
• Claim Formats: EDI X12 formats like 837P/I/D, X12 formats 835, 834, 270/271, 276/277
• Claim System: Familiarity with systems like CMdS, GHS, Facets and etc
• SQL: To validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan)
• EDI Tools: Validating X12 files
• Interface Testing: Understanding how data flows between systems and formats and use tools like postman

Preferred Skills

• Minimum of 8+ years of experience in health care experience especially in MMIS domain
• Capability to think out-of-the-box to create new solutions as needed
• Ability to validate Test scenarios and test plans, test data
• Should be able to Review requirements, documentation and create Requirements Traceability matrix (RTM)
• Should have excellent communication (written and spoken) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units
• Ability to assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product
• Ability to drive and share the requirements with Technical and Architects regarding product features to be implemented
• Communication: Collaborate with cross-functional teams
• Flexible Working