Senior Healthcare Business Analyst (Payer Claims / Medicare / Medicaid)

Job Title: Senior Healthcare Business Analyst (Payer Claims / Medicare / Medicaid)

Location: [Remote]
Employment Type: Full-Time

Job Description

We are seeking an experienced Senior Healthcare Business Analyst with extensive knowledge of the healthcare payer domain and strong expertise in commercial claims processing, Medicare, and Medicaid systems. The ideal candidate will serve as a liaison between business stakeholders and technical teams, driving requirements gathering, solution design, and successful implementation of healthcare claims solutions.

Key Responsibilities

• Gather, analyze, document, and manage business and functional requirements from clients and stakeholders.
• Work closely with clients to understand business processes and translate requirements into detailed specifications.
• Participate in the implementation and maintenance of commercial payer claims solutions and/or Medicare/Medicaid systems.
• Demonstrate strong understanding of healthcare claims processing concepts, including claims adjudication, provider management, member enrollment, and care management.
• Utilize healthcare reference code sets such as CPT, CDT, HCPCS, ICD-9, and ICD-10 in claims-related analysis and documentation.
• Configure and support benefits and program setup across various claims processing subsystems.
• Adhere to established processes for requirements elicitation, documentation, review, and handoff to development teams.
• Collaborate with development, architecture, and design teams to clarify requirements and identify optimal solution approaches.
• Facilitate brainstorming sessions and support the delivery of best-in-class healthcare solutions.
• Create interface mapping documents detailing business rules, data transformations, and database mappings.
• Conduct system analysis, perform root cause analysis (RCA), and execute data validation using SQL queries.
• Support development activities by reviewing deliverables and ensuring alignment with business requirements.
• Coordinate with clients and internal teams throughout the development lifecycle.
• Conduct demonstrations at milestone completions, gather feedback, track action items, and ensure closure.
• Participate in GUI and platform requirement discussions to support product design and usability initiatives.
• Maintain effective communication with stakeholders across business, technical, and client organizations.

Required Qualifications

• Bachelor's degree in Business, Healthcare, Information Technology, or a related field.
• Minimum 10 years of experience in the healthcare payer domain.
• Prior experience implementing or supporting commercial payer claims solutions and/or Medicare/Medicaid systems.
• Strong knowledge of:
  • Claims Processing and Claims Adjudication
  • Provider and Member Enrollment
  • Care Management
  • Benefits and Program Configuration
  • Healthcare code sets including CPT, CDT, HCPCS, ICD-9, and ICD-10
• Experience in requirements elicitation, documentation, and stakeholder management.
• Working knowledge of web services, relational databases, and SQL.
• Experience creating interface mapping documents and documenting business rules.
• Strong analytical, problem-solving, and multitasking abilities.
• Excellent verbal and written communication skills.

Preferred Qualifications

• Prior experience working as a QA Analyst or Developer within healthcare systems.
• Ability to validate test scenarios, test plans, and test data.
• Experience creating and maintaining Requirements Traceability Matrices (RTM).
• Ability to assess current product capabilities against market trends and regulatory requirements.
• Experience driving discussions with architects and technical teams regarding future product enhancements.
• Strong collaboration skills with QA, development, business users, and client stakeholders.

Preferred Tools & Technologies

• MS Visio
• Jira
• Azure DevOps
• TFS (Team Foundation Server)
• SQL / Database Query Tools
• Microsoft Office Suite

Key Skills

Healthcare Payer, Medicare, Medicaid, Commercial Claims Processing, Claims Adjudication, Provider Enrollment, Member Enrollment, Care Management, Benefits Configuration, CPT, CDT, HCPCS, ICD-9, ICD-10, Requirements Gathering, BRD, Functional Requirements, RTM, SQL, Data Mapping, Interface Mapping, RCA, UAT, Agile, SDLC, Jira, Azure DevOps, MS Visio, Stakeholder Management, Healthcare Business Analysis.