Job Title: Senior Healthcare Business Analyst / Behavioral Health SME
Experience: 10+ Years
Domain: Healthcare Payer | Behavioral Health (BH)
Role Overview
Seeking a seasoned Behavioral Health SME with strong Business Analyst and healthcare systems expertise to support payer transformation initiatives. The ideal candidate will have deep knowledge of Behavioral Health operations, end-to-end payer processes, and healthcare regulations, along with the ability to bridge business and technology teams.
Key Requirements
10+ years of Healthcare Payer experience with 5+ years in Behavioral Health (Mental Health & Substance Use Disorders).
Strong understanding of the end-to-end payer lifecycle:
Eligibility & Enrollment
Benefits Configuration
Claims Processing & Adjudication
Prior Authorization
Care & Case Management
Provider Management
Appeals & Grievances
Payment Integrity
Deep knowledge of Behavioral Health regulations, including:
MHPAEA (Mental Health Parity)
Medicare & Medicaid BH programs
HIPAA
CMS and State-specific regulatory requirements
NCQA/URAC standards
Strong Business Analysis skills:
Requirements gathering
BRD/FRD/User Stories
Process mapping
Gap analysis
UAT/SIT support
Stakeholder management
Experience with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare, or similar.
Knowledge of healthcare transactions and interoperability standards:
837, 835, 834, 270/271
HL7/FHIR
Strong SQL, data analysis, and system integration understanding.
Preferred
Experience with Commercial, Medicare, and Medicaid lines of business.
Exposure to Behavioral Health care management, utilization management, and value-based care programs.
Experience working on payer modernization, data, AI, or digital transformation initiatives.
Ideal Candidate
The ideal candidate will be a Behavioral Health payer SME who combines deep business process knowledge, regulatory expertise, system knowledge, and business analysis skills, with proven experience across:
Behavioral Health + Claims + Eligibility + Benefits + Care Management + Provider Operations + Regulatory Compliance + Payer Technology Platforms.
This person should be capable of driving both strategic business discussions and detailed system-level solution design discussions with equal effectiveness.
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