Technical Business Analyst (IT healthcare)

About the role

Collaborate with business stakeholders, clinical teams, and IT development teams to analyze, document, and implement healthcare business and technical requirements.

Act as the liaison between business users and software development teams to support healthcare payer systems and business process improvements.

Responsibilities

• Analyze healthcare policies, claims processing workflows, and coding requirements to recommend effective business and technical solutions.
• Support medical review, appeals, program integrity, and healthcare compliance initiatives.
• Interpret and apply ICD, CPT, and HCPCS coding guidelines to support business processes and system enhancements.
• Perform business process analysis, gap analysis, workflow documentation, and requirements gathering for healthcare IT projects.
• Work closely with developers, testers, and project managers throughout the Software Development Life Cycle (SDLC).
• Validate system functionality and participate in User Acceptance Testing (UAT) to ensure business requirements are met.
• Review healthcare claims, coding methodologies, and reimbursement policies to ensure regulatory compliance and operational accuracy.
• Utilize medical coding software and claims processing systems to analyze data and support business decisions.
• Develop business documentation including functional specifications, process flows, business requirements, and user guides.
• Support policy remediation initiatives and recommend process improvements to enhance operational efficiency.
• Collaborate with cross-functional teams to resolve complex business and technical issues.
• Maintain compliance with healthcare regulations, coding standards, and organizational policies.
• Provide subject matter expertise for healthcare payer operations and clinical business processes.

Requirements

• ICD-10 proficiency certification or the ability to obtain certification within one year of employment.
• 10+ years of experience in healthcare insurance, medical review, program integrity, or appeals.
• 5+ years of experience working with IT developers/programmers in a healthcare payer environment.
• 5+ years of medical coding experience in a payer environment.
• 3+ years of direct clinical experience in a healthcare setting with strong clinical assessment and critical thinking skills.
• 5+ years of experience with ICD, CPT, and HCPCS coding methodologies and translation.
• 5+ years of knowledge in anatomy, physiology, pharmacology, and medical terminology.
• 5+ years of experience supporting policy remediation initiatives.
• 5+ years of experience with healthcare claims processing systems.
• 5+ years of proficiency with Microsoft Office applications.
• 5+ years of experience using Optum Encoder and/or other medical coding software applications.
• Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN).
• Current, active, and unrestricted Registered Nurse (RN) license issued by the State of South Carolina.
• Current Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification.

Qualifications

• Strong analytical, problem-solving, and critical thinking abilities.
• Excellent verbal and written communication skills.
• Experience gathering and documenting business requirements for healthcare IT initiatives.
• Knowledge of healthcare payer operations, claims adjudication, and reimbursement processes.
• Experience supporting cross-functional teams in Agile or Waterfall project environments.
• Ability to manage multiple priorities while working collaboratively with technical and business stakeholders.