Claims Management Platform BA

Claims Management Platform BA

Experience: 10– 20 years

Location: Onsite to Georgia Atlanta (Relocation is Ok) FTE only

Visa - ,GC

Need small writeup in submission email on Primary skills and it should reflect with exact no. of experience on resume too –

Writeup Skills

• Experience with enrollment and eligibility workflows, including COBRA, Leave of Absence, and Coordination of Benefits (COB).
• US Health Insurance domain experience
• US Health Insurance, Stop-Loss, TPA, Payer, Claims, or Data Platform programs.
• Stakeholder engagement, business process analysis, and backlog refinement.
• Claims data quality, reconciliation, duplicate detection, record matching, and entity resolution.
• Resolve conflicting business rules, and drive consensus across stakeholders.

Primary Skills (Must-Have)

• 10+ years of experience as a Senior Business Analyst on data or US Health Insurance domain experience.
• 8+ years of experience in US Health Insurance, Stop-Loss, TPA, Payer, Claims, or Data Platform programs.
• 10+ years in requirements management, stakeholder engagement, business process analysis, and backlog refinement.
• 5+ years defining complex business rules, eligibility criteria, rule catalogs, and data governance requirements.
• 5+ years in claims data quality, reconciliation, duplicate detection, record matching, and entity resolution.
• Strong ability to identify requirement gaps, resolve conflicting business rules, and drive consensus across stakeholders.
• 5+ years partnering with Product Owners, SMEs, Development, QA, and Project Managers to deliver business outcomes and ensure solution alignment.

Secondary Skills (Good-to-Have)

• Experience with enrollment and eligibility workflows, including COBRA, Leave of Absence, and Coordination of Benefits (COB).
• Working knowledge of SQL to validate business rules and analyze data directly.
• Familiarity with healthcare claims and member eligibility processes.
• Exposure to data migration, data transformation, and data quality initiatives within healthcare or insurance domains.

Soft Skills / Other Skills

• Communication Skills: Communicate effectively with stakeholders. Use clear verbal, written (emails, documentation), and instant messaging approaches to ensure alignment.
• Interpersonal Skills: Build and maintain productive relationships across cross-functional teams. Provide constructive feedback during requirement workshops and be open to stakeholder input.
• Problem-Solving & Analytical Thinking: Strong analytical mindset to evaluate process flows. Ability to troubleshoot requirement gaps, compliance risks, and process inefficiencies.
• Task / Work Updates: Prior experience working in Agile/Scrum projects with tools like Jira or Azure DevOps. Provide regular updates, demonstrate proactivity, and show due diligence in carrying out responsibilities.
• Stakeholder Management: Skilled in facilitating workshops, UAT sessions, and requirement walkthroughs. Act as a liaison between business and technical teams, ensuring clarity and consensus.

Overview & Role Summary

• Educational Qualification: MBA or Any Bachelors degree with extensive experience in Business Analysis.
• Experience Range: 10-12 Years of Experience.
• Tagline / Tech Stack Snapshot: Senior Business Analyst | Requirements Management | Claims Operations | Stakeholder Collaboration.
• Role Summary: Experienced Business Analyst with strong health insurance and stop-loss expertise, responsible for partnering with Product Owners, SMEs, and stakeholders to translate claims and eligibility processes into clear, versioned, and testable business rules. Ensures proposed solutions align with business requirements, proactively identifies gaps and discrepancies, and enables engineering teams to build accurate, scalable solutions.

Why This Role Matters

The Business Analyst is the bridge between stakeholders and technical delivery teams, ensuring that the Claims Management Platform is not only implemented but also aligned with regulatory, operational, and analytical needs. In a highly regulated environment, success depends on translating complex functional, non-functional and regulatory requirements into actionable, compliant solutions. This role matters because:

• It ensures regulatory confidence by embedding HIPAA requirement.
• It drives operational efficiency by reducing manual data transfers, enabling secure vendor collaboration, and standardizing workflows.
• It enables analytics readiness by defining requirements for dashboards, scorecards, and validated pipelines in Microsoft Fabric and Power BI.
• It fosters stakeholder alignment by facilitating workshops, UAT sessions, and milestone sign-offs.

What You'll Do / Job Description of Role (RNR)

• Write and maintain the rule set that governs how claims data is cleaned, standardised, and combined — including how corrections, reversals and duplicate claims are handled.
• Own the project backlog. Work with customer Product Owner, stakeholders, SMEs, and WinWire team to iteratively refine the backlog to ensure it meets the customer requirements.
• Collaborate with WinWire Project Manager to identify and escalate scope creep and schedule/timeline risks.
• Define the rules for deciding whether two records describe the same person, and where the system should stop and ask a human.
• Define the eligibility rules: what information is required for each type of member, where the system should look for it internally before asking the provider, and what triggers a follow-up.
• Facilitate regular working sessions with business and claims SMEs to align on requirements, validate business rules, and ensure timely decision-making.
• Perform gap analysis between documented requirements, current-state processes, and proposed solutions, proactively identifying risks, ambiguities, and improvement opportunities.
• Define baseline operational metrics and success measures to quantify business outcomes, efficiency gains, and platform value realization.
• Develop clear business requirements, user stories, acceptance criteria, and user acceptance testing (UAT) scenarios in partnership with QA and business stakeholders.
• Write acceptance criteria and user acceptance test scripts alongside the QA leads.
• Act as the bridge between business and technical teams, ensuring business needs are translated into scalable, actionable, and well-governed solution designs.