Claims Processing Expertise with Healthcare Domain Expert

Business Analysis & Solution Design

• Elicit, analyze, and document complex business, operational, and system requirements
• Translate business problems into functional requirements, workflows, process models, and user stories

Payment Integrity & Healthcare Domain Analysis end to end Claims

• 10+ years of Business Analysis / Business Systems Analysis experience
• Strong U.S. Healthcare experience working with all Lines of businesses
• Payment Integrity, Claims, FWA/Revenue Cycle Management experience

lifecycle of a claim, Claim Processing, Claim Auditing is a “MUST”.

• Analyze the end-to-end Payment Integrity lifecycle, from pre-submission and pre-adjudication prevention through Prepay intervention, Postpay audit, overpayment recovery, and continuous improvement. PI spans eligibility, coding, billing, pricing, clinical evidence, provider contracts, payment policies, and regulatory requirements.
• Support Pre-adjudication and front-end prevention by translating payment policies, coding and reimbursement guidelines, eligibility rules, and provider-facing error-prevention requirements into business rules, workflows, alerts, and actionable messaging that help promote clean-claim submission and avoid preventable denials.
• Analyze Prepay capabilities including automated and manual claim edits, analytical claim selection, clinical and non-clinical reviews, medical-record and itemized-bill validation, correct-coding and reimbursement-policy checks, and claim routing or intervention outcomes such as allow, adjust, hold, pend, or deny.
• Support Postpay and Recovery workflows that identify overpayments after adjudication, perform retrospective audit and investigation, validate findings, coordinate claim adjustments and recovery activities, and track cases through resolution while maintaining clear evidence and audit trails.
• Perform root-cause analysis on Postpay findings, appeals, adjustments, recovery results, and repeat billing patterns to identify opportunities to shift recurring leakage upstream into Prepay edits, payment policies, provider education, or other preventive controls.
• Apply working knowledge of cross-cutting PI capabilities including Waste and Error, Clinical PI, Facility Audit, Claims Cost Management, Payment Policy, Audit and Recovery, Fraud/Waste/Abuse, Coordination of Benefits, Subrogation, payment primacy, and avoided-spend initiatives.
• Analyze COB, Subrogation, and payment-primacy scenarios to support accurate identification of primary coverage, third-party liability, payer responsibility, and related prepay avoidance or postpay recovery workflows.
• Evaluate PI scenarios across commercial, Medicare, Medicaid, ASO, and other applicable lines of business, considering claim type, professional versus facility billing, reimbursement methodology, provider specialty and behavior, member eligibility and utilization context, state or regulatory requirements, and clinical versus non-clinical review needs.