Business Analyst - Healthcare Payer

Role: Business Analyst (Healthcare Payer Government Programs/Risk Adjustment)

Duration: 06 Months with Possible extension

Location: 100% REMOTE (EST candidates strongly preferred)

Key Responsibilities

• Elicit, analyze, and document business requirements for initiatives impacting government programs, including risk adjustment, care management, claims, and provider engagement
• Support risk adjustment programs, including data validation, gap identification, suspecting logic, and performance tracking
• Collaborate with clinical and coding teams to ensure accurate HCC capture and documentation improvement strategies
• Analyze large datasets (claims, encounters, clinical data) to identify trends, gaps, and opportunities for improved RAF scores and quality outcomes
• Develop and maintain business process flows, data mappings, and functional specifications
• Facilitate cross-functional workshops and stakeholder meetings to align on scope, priorities, and solutions
• Support regulatory compliance initiatives (CMS, state Medicaid agencies), including audit readiness (e.g., RADV)
• Perform UAT planning and execution, including test case development and defect tracking
• Create executive-ready summaries, dashboards, and reports to communicate key insights and program performance
• Identify process improvement opportunities and support automation, workflow optimization, and operational efficiency initiatives

Required Qualifications

• Bachelor''s degree in Healthcare Administration, Business, Information Systems, or related field
• 5+ years of Business Analyst experience within a healthcare payer organization
• Direct experience supporting government programs (Medicaid, Medicare Advantage, Duals, ACA Exchange)
• Knowledge of risk adjustment models and processes (CMS-HCC, HHS-HCC)
• Experience working with claims, enrollment, provider, and clinical datasets
• Proficiency in requirements documentation (BRDs, FRDs, user stories) and process modeling
• Experience with data analysis tools (e.g., SQL, Excel, or BI tools such as Power BI/Tableau)
• Excellent communication skills with ability to interface with both business and technical stakeholders

Preferred Qualifications

• Experience with value-based care programs, quality initiatives (HEDIS, Star Ratings)
• Familiarity with coding guidelines (ICD-10, CPT) and clinical documentation improvement (CDI) practices
• Exposure to care management platforms, population health tools, or risk adjustment vendors
• Agile/Scrum experience and familiarity with tools such as Jira or Azure DevOps