Healthcare Claims Business Analyst / SME

About the role

The Healthcare Claims Business Analyst / Subject Matter Expert (BA/SME) serves as InfoMC's primary domain authority for healthcare claims operations during new client onboarding engagements on the Incedo claims platform. This individual bridges the gap between client operational workflows and the technical capabilities of the Incedo solution, ensuring that each implementation is aligned with payer-side business requirements, regulatory obligations, and industry standards for electronic data interchange (EDI).

Responsibilities

• Serve as the internal and client-facing subject matter expert on healthcare claims operations, EDI transaction standards, and payer-side adjudication logic throughout the Incedo onboarding lifecycle
• Translate client payer workflows and claims processing requirements into detailed business and functional specifications for the Incedo implementation team
• Advise clients on best practices for configuring claims intake, adjudication rules, coordination of benefits (COB), appeals and grievance workflows, and remittance processing within Incedo
• Identify gaps between client legacy processes and Incedo capabilities; document and escalate to product/engineering as applicable
• Support clients in designing claims data migration strategies, including crosswalks from legacy systems and validation of historical claims data integrity
• EDI Transaction Set Knowledge & Validation
• The BA/SME must possess hands-on functional knowledge of the following HIPAA-mandated ASC X12 Transaction Sets and their application in a payer environment:
• 834 - Benefit Enrollment and Maintenance: member eligibility file intake from CMS, employer groups, or TPAs; validation of enrollment spans, plan codes, and subscriber/dependent relationships
• 270 / 271 - Eligibility Inquiry and Response: real-time and batch eligibility verification, configuration of response logic and benefit information, and integration with member enrollment systems
• 837P / 837I - Professional and Institutional Claims: inbound claims intake, loop and segment validation, NPI/taxonomy routing, and coordination with Incedo adjudication engine
• 835 - Healthcare Claim Payment/Advice (ERA): remittance generation, CAS segment coding, ERA reconciliation against adjudicated claims, and ERA/EFT pairing
• 276 / 277 - Claim Status Request and Response: outbound claims status inquiry workflows, 277CA acknowledgment processing, and payer-to-provider communication configuration
• 278 - Health Care Services Review (Prior Authorization): inbound and outbound PA request/response workflows, integration with Incedo utilization management module, and CMS-0057-F electronic PA compliance
• 275 - Patient Information (Additional Information to Support a Health Care Claim): receipt and routing of clinical attachments and supporting documentation submitted by providers in conjunction with claims, including coordination with Incedo adjudication workflows requiring medical records or authorization documentation
• 999 / TA1 - Functional Acknowledgment and Interchange Acknowledgment: EDI gateway configuration, acknowledgment tracking, and error-handling workflows

Requirements

• Deep payer-side experience with HIPAA-mandated EDI transactions, CMS reporting requirements, and the operational realities of claims processing within Medicare Advantage, Medicaid, and commercial health plan environments

Qualifications

• Bachelor’s degree in healthcare administration, information technology, or a related field
• Minimum 5 years of experience in healthcare claims operations, preferably in a payer environment
• Strong understanding of healthcare regulations, including HIPAA, HITECH, and other relevant laws
• Experience with ASC X12 transaction sets and EDI interoperability
• Excellent communication and interpersonal skills, with the ability to effectively collaborate with both technical and non-technical stakeholders
• Proficiency in Microsoft Office Suite, particularly Excel for data analysis and report creation

Skills

• Strong analytical and problem-solving skills
• Ability to manage multiple projects simultaneously and meet deadlines
• Excellent written and verbal communication skills
• Knowledge of healthcare claims processing and regulatory requirements
• Experience with healthcare claims data migration and validation
• Hands-on experience with ASC X12 transaction sets and EDI interoperability

Benefits

• Competitive salary commensurate with experience
• Flexible work schedule
• Professional development opportunities
• Health and wellness programs

Pay

• Competitive salary commensurate with experience

Schedule

• Full-time position