Healthcare Federal Program Business Analyst

Overview

Remote
Depends on Experience
Contract - Independent

Skills

CMS
EDI
SQL

Job Details

Overview

We are seeking an experienced Business Analyst with strong expertise in U.S. Healthcare Federal Programs including Medicare, Medicaid, ACA, CHIP, CMS regulatory reporting, and HIPAA compliance. The ideal candidate will analyze business processes, translate regulatory requirements into system solutions, support data validation, and ensure compliance with federal and state mandates.

Key Responsibilities

  • Conduct requirements gathering sessions with stakeholders from Eligibility, Enrollment, Claims, Provider, Pharmacy, and Care Management.
  • Translate CMS and State Medicaid policies into clear business and functional requirements.
  • Document As-Is and To-Be workflows and identify process improvements.
  • Interpret and implement CMS rules, state Medicaid guidelines, ACA standards, HIPAA 5010, NCQA, HEDIS, and URAC requirements.
  • Support CMS/state audits and ensure compliance with reporting standards (T-MSIS, HEDIS, encounter reporting).
  • Perform analysis of eligibility, claims, provider, pharmacy, and encounter data.
  • Create data mapping and validation rules for EDI transactions (834, 837, 820, NCPDP, FHIR).
  • Create BRDs, FRDs, user stories, acceptance criteria, and workflow diagrams.
  • Develop test scenarios for SIT/UAT focused on benefits, claims, and encounter processing.
  • Work with Developers, QA, ETL/BI teams, Architects, and Product Owners to ensure alignment.
  • Coordinate with external vendors (TPAs, PBMs, clearinghouses) and government agencies.

Required Skills & Experience

  • 5+ years of Business Analyst experience in Healthcare Federal Programs (Medicare, Medicaid, ACA, CHIP).
  • Strong understanding of CMS guidelines, encounter reporting, T-MSIS, HIPAA, HEDIS, and NCQA.
  • Hands-on experience with EDI transactions (834/837/820/NCPDP) and FHIR integrations.
  • Proficiency in SQL for data analysis and validation.
  • Experience working in Agile methodologies.
  • Strong communication, documentation, and stakeholder management skills.

Preferred Qualifications

  • Experience with MMIS, MCO operations, PBM systems, or Care Management platforms.
  • Knowledge of healthcare pricing, benefits configuration, and claims adjudication.
  • Experience supporting CMS/state audits.
  • Certifications: CBAP, PMI-PBA, Scrum Master, HIPAA.
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