Healthcare Lead Business Analyst

Remote Role but only within USA

Full Time

We are seeking an experienced Healthcare Lead Business Analyst with strong payer-side expertise and payments/financial processing experience. The role will involve leading business analysis activities across claims, benefits, enrollment, and payment lifecycle initiatives, while working closely with business stakeholders, product owners, and technology teams to deliver compliant and scalable healthcare solutions.
Key Responsibilities

• Lead business analysis efforts for payer-side healthcare systems including claims, enrollment, benefits, provider, and payments.
• Work extensively on claims processing and adjudication, including medical, dental, hospital, and pharmacy claims.
• Support initiatives related to payments, including claims payments, adjustments, denials, remittances (EOB/EOP), provider payments, and reconciliation.
• Elicit, analyze, document, and validate business and system requirements from internal and external stakeholders.
• Translate business needs into functional requirements, user stories, BRDs, and FRS documents.
• Collaborate closely with technical teams to ensure accurate implementation of requirements.
• Perform gap analysis, impact analysis, and support solution design decisions.
• Ensure compliance with US healthcare regulations (HIPAA, CMS, ACA) and payer operational guidelines.
• Participate in Agile/Scrum and Waterfall delivery models; support sprint planning, grooming, UAT, and production release activities.
• Mentor junior business analysts and establish BA best practices.

Required Skills & Experience

• 10+ years of experience as a Business Analyst in US Healthcare, with strong payer-side exposure.
• Deep understanding of healthcare claims adjudication, claim edits, pricing, and audit processes.
• Strong experience with healthcare payments, including claims payments, provider reimbursement, adjustments, reversals, and financial reconciliation.
• Knowledge of Revenue Cycle Management, including:

• Benefit plans
• Member eligibility
• Provider data
• Claims operations
• Financial workflows

• Working knowledge of medical coding systems (CPT, HCPCS, ICD, DRG, Revenue Codes, Modifiers).
• Experience with Medicaid (MMIS) and/or commercial payer systems is highly preferred.
• Exposure to EDI transactions (837, 835, 834)
• Strong documentation and communication skills; ability to interact with business, technical, and executive stakeholders.
• Hands-on experience with Agile tools (JIRA, Confluence) and requirement management processes.

Preferred Qualifications

• Experience working with State Medicaid or Medicare programs
• Prior experience leading large-scale payer transformation or modernization initiatives