We are seeking an experienced Healthcare Business Systems Analyst (BSA) with strong knowledge of healthcare claims processing and pre-adjudication workflows. The ideal candidate will have hands-on experience analyzing healthcare EDI transactions, claim intake and validation processes, and the flow of claims from trading partners through pre-adjudication and into the core claims adjudication system.
Key Responsibilities
* Analyze and document end-to-end healthcare claim workflows, with a strong focus on pre-adjudication processing.
* Work extensively with 837 Professional (837P) and Institutional (837I) claim transactions.
* Understand the claim lifecycle from provider/trading partner → clearinghouse/gateway → EDI/pre-adjudication platform → core adjudication system.
* Analyze pre-adjudication processes including:
* File and transaction validation
* HIPAA/X12 compliance validation
* Trading partner and submitter validation
* Member and provider validation
* Duplicate and business-rule validations
* Claim balancing and control totals
* Claim acceptance/rejection
* Error handling and exception processing
* Strong understanding of 999 Functional Acknowledgment and 277CA Claim Acknowledgment transactions and their relationship to 837 processing.
* Analyze rejected claims and identify whether issues originate from the trading partner, EDI/pre-adjudication layer, mapping/transformation logic, or downstream claims system.
* Gather and translate business requirements into business requirements, functional requirements, user stories, process flows, mapping documents, and acceptance criteria.
* Conduct requirements-gathering sessions with business, EDI, claims operations, development, testing, and vendor teams.
* Perform gap analysis and impact analysis for new implementations and changes to existing claim-processing workflows.
* Support SIT/UAT by developing test scenarios, reviewing test results, validating claim outcomes, and assisting with defect analysis.
* Work closely with technical teams to troubleshoot production issues involving claim intake, validation, rejection, and downstream processing.
Required Qualifications
* 5+ years of Business Systems Analyst experience, preferably within healthcare payer environments.
* Strong hands-on knowledge of healthcare claims and pre-adjudication processes.
* Strong understanding of HIPAA X12 EDI transactions, particularly:
* 837P
* 837I
* 999
* 277CA
* Good understanding of Professional and Institutional claims and associated claim and service-line data.
* Experience working with Medicaid and/or Medicare managed care environments preferred.
* Understanding of the distinction between pre-adjudication edits/rejections and claims adjudication edits/denials.
* Experience documenting as-is/to-be workflows, business rules, functional requirements, user stories, and acceptance criteria.
* Strong analytical and troubleshooting skills, including the ability to trace claims across multiple systems.
* Experience with SQL/data analysis for claim research and validation is highly preferred.
* Experience working in Agile/Scrum environments and Jira is preferred.
Preferred Experience
Experience with healthcare payer core administration and EDI platforms such as Facets or similar claims systems, EDI gateways/translators, clearinghouses, and claim intake/pre-adjudication applications is highly desirable.
Primary Skill: Healthcare BSA – Claims Pre-Adjudication
Secondary Skills: 837P/837I, 999, 277CA, HIPAA X12, Claims Processing, Requirements Analysis, SQL, Jira
Industry: Healthcare Payer / Medicaid / Medicare
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