Claims Module Senior Business Analyst

About Our Client

The organization operates within the healthcare and government services sector, delivering mission-critical solutions and services to Fortune 100 companies and over 500 government entities. It addresses the challenges of managing complex healthcare and administrative processes by providing tailored technology and consulting services that impact millions of people relying on these systems.

About the Opportunity

The Claims Module Senior Business Analyst serves as the Claims Domain lead for MMIS healthcare projects. This role is pivotal in guiding claims processes and ensuring that business requirements are accurately analyzed and translated into system designs. The position supports customer implementation decisions and helps maintain quality throughout development cycles, contributing directly to the effectiveness and reliability of healthcare claims management.

Responsibilities

• Lead the claims module and provide domain expertise.
• Analyze business requirements related to claims processing.
• Design and develop documentation ensuring quality standards.
• Collaborate with customers and coordinate feedback.
• Work within teams to guide projects through the full lifecycle.
• Manage customer expectations and troubleshoot application issues.
• Assist customers with implementation decisions.

Requirements

• Strong healthcare domain experience, specifically Medicaid and Medicare.
• Hands-on experience with claims processing and adjudication.
• Knowledge of reference code/data sets used in claims adjudication.
• Experience configuring benefits or programs in claims systems.
• Ability to run queries and perform system analysis including root cause analysis.
• Effective communication skills for interacting with clients and internal teams.
• Experience collaborating with development, architecture, and design teams.
• In-depth understanding of claims lifecycle including member, provider, claim submission, adjudication, payment cycle, and reporting.
• Familiarity with claim types such as professional, dental, institutional, pharmacy, encounters, and capitation.
• Knowledge of EDI X12 claim formats (837P/I/D, 835, 834, 270/271, 276/277).
• Familiarity with claim systems like CMdS, GHS, Facets.
• Proficiency in SQL for backend data validation.
• Experience with EDI tools for validating X12 files.
• Understanding of interface testing and data flow between systems.
• Minimum of 8 years in healthcare, particularly in MMIS domain preferred.
• Ability to validate test scenarios, plans, and data.
• Skills in reviewing requirements and creating traceability matrices.
• Capability to assess product functionality against market trends and regulatory needs.
• Collaborative communication with cross-functional teams.

Pay

The estimated salary range for this role is $85,470 - $111,000. This position may be eligible for bonuses or incentives based on business need.

Benefits

• Health insurance coverage.
• Voluntary dental and vision programs.
• Life and disability insurance.
• Retirement savings plan.
• Paid holidays.
• Paid time off and sick leave.
• Remote work flexibility.