Required Skills:
1. Healthcare Claims Processing
2. Pega
3. Facets (Claims, Membership, Billing, Provider)
4. EDI 837/835
5. Business Analysis
Job Description:
• Gather, analyze, and document business and system requirements for healthcare claims processing initiatives.
• Work closely with business stakeholders, product owners, developers, and QA teams to ensure requirements are accurately defined and implemented.
• Analyze healthcare claims workflows including claims intake, adjudication, adjustments, provider reimbursement, and payment processing.
• Work with Facets modules including Claims, Membership, Billing, and Provider to support end-to-end claims lifecycle management.
• Translate business requirements into functional specifications, user stories, process flows, and acceptance criteria.
• Analyze member, provider, claims, benefits, and authorization data to support operational and system enhancement initiatives.
• Support Agile development activities including backlog grooming, sprint planning, testing, defect triage, and release activities.
• Participate in requirements workshops, stakeholder discussions, and solution design reviews.
• Support User Acceptance Testing (UAT), validate business requirements, and assist with production issue analysis.
• Ensure healthcare claims requirements and workflows align with HIPAA and EDI 837/835 transaction standards.
