Position: Senior Clinical Business Systems Analyst (Clinical BSA)
Location: Remote
Employment: Contract
Job Description:
Seeking a Senior Clinical BSA with 10+ years of healthcare payer experience, focused on Population Health, Utilization Management (UM), and Care/Case Management (CM). This role acts as a clinical + functional SME, supporting Medicaid/Medicare initiatives to improve care delivery, outcomes, and compliance.
Duties:
Population Health, UM & Care Management
Clinical SME for systems supporting Pop Health, UM, and CM
Analyze and document end‑to‑end clinical workflows, including:
Care plans
Prior authorizations & utilization review
Clinical assessments
Care coordination & transitions of care
Convert clinical and business needs into:
Functional requirements
User stories
Acceptance criteria
Support initiatives around:
Risk stratification
Care gap identification/closure
Member outreach
Outcomes and quality tracking
Clinical Process & Requirements Analysis
Perform gap analysis, impact analysis, and process modeling
Create and maintain:
BRDs / FRDs
Workflow diagrams
Data mappings & traceability matrices
Partner with clinical ops, medical management, and compliance teams
Ensure solutions align with evidence‑based care models and regulations
Data Analysis & Reporting
Use SQL to validate:
Care management data
Authorization decisions
Clinical outcomes & quality measures
Utilization metrics
Work with data/reporting teams to ensure clinical data accuracy
Stakeholder Collaboration
Act as a bridge between:
Clinical teams (nurses, care managers, medical directors)
Business stakeholders
IT, data, and integration teams
Lead cross‑functional sessions
Present complex concepts to non‑technical stakeholders
Manage backlog and priorities in Agile/Scrum
Testing, Quality & Compliance
Define and support UAT
Validate clinical workflows and authorization logic
Support defect triage with QA teams
Ensure compliance with:
HIPAA
CMS guidelines
State Medicaid regulations
Support audits and PHI/PII security reviews
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