Senior Business Analyst with Claims module

About the Role

Play the role of Claims Domain lead for MMIS health care projects. Drive the claims module and process, provide domain knowledge, perform analysis of business requirements, design and develop documentation, ensure quality process, and coordinate with customers. Work in a team environment and provide guidance throughout the entire life cycle. Responsible for meeting customer expectations, troubleshooting problems in the application, and assisting customers in implementation decisions.

Responsibilities

• Lead the claims module and process for MMIS healthcare projects.
• Analyze business requirements and design documentation.
• Ensure quality processes and coordinate with customers.
• Troubleshoot application problems and assist in implementation decisions.
• Work closely with clients and development teams during development stages.
• Conduct demos at milestone completion, track, and close feedback.
• Collaborate with Dev, Architecture, and Design teams to define GUI views and platform requirements.
• Validate test scenarios, test plans, and test data.
• Review requirements and documentation, and create Requirements Traceability Matrix (RTM).
• Assess current product functionality against market trends and regulatory requirements.
• Drive and share requirements with Technical and Architect teams for product features.
• Run queries and perform basic system analysis, including Root Cause Analysis (RCA).

Requirements

• Minimum of 8+ years of experience in healthcare, especially in the MMIS domain.
• Strong healthcare domain experience with good knowledge of Medicaid and Medicare.
• Hands-on experience in claims processing and adjudication processes.
• Experience with reference code/data sets required in claims adjudication.
• Prior experience or understanding in configuring benefits or programs in claims systems across various subsystems.
• In-depth understanding of the claims lifecycle, including:
  • Member Provider Claim submission (Paper and EDI X12)
  • Adjudication
  • Payment Cycle (Finance)
  • Reporting
• Familiarity with claim types:
  • Professional
  • Dental
  • Institutional
  • Pharmacy
  • Encounters and Capitation
• Knowledge of claim formats:
  • EDI X12 formats like 837P/I/D
  • X12 formats 835, 834, 270/271, 276/277
• Familiarity with claim systems like CMdS, GHS, Facets, etc.

Skills

• SQL: Validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan).
• EDI Tools: Validate X12 files.
• Interface Testing: Understand data flow between systems and formats; use tools like Postman.
• Excellent written and spoken communication skills to engage with stakeholders (QA/dev team, clients, end users, business units).
• Ability to multitask between internal teams and clients based on priority.
• Capability to think out-of-the-box to create new solutions as needed.