Claims Module Senior Business Analyst

Role Overview

Claims Module Senior Business Analyst (Claims Domain Lead) for MMIS healthcare projects. You will lead the claims domain, partner with customers and product/development teams, and ensure end-to-end quality across requirements, documentation, demos, and troubleshooting.

Responsibilities

• Drive the claims module and supporting processes, providing deep claims domain knowledge
• Analyze business requirements and translate them into clear documentation and artifacts
• Design and develop documentation, ensuring quality processes while coordinating with customers
• Guide stakeholders throughout the full project lifecycle
• Meet customer expectations; troubleshoot application issues
• Support customers with implementation decisions
• Work closely with Dev, architecture, and design to define GUI view and platform requirements
• Conduct demos at milestone completion; track and close feedback
• Work with cross-functional teams to define and share requirements for product features
• Support validation through requirements traceability and testing artifacts (e.g., RTM, test scenarios/data)

Key Claims / Healthcare Domain Scope

• Claims lifecycle: Member, Provider, Claim submission (Paper and EDI X12), Adjudication, Payment Cycle (Finance), Reporting
• Claim types: Professional, Dental, Institutional, Pharmacy, Encounters, Capitation
• Claim formats and EDI standards: EDI X12 such as 837P/837I/837D, 835, 834, 270/271, 276/277
• Claims systems familiarity (examples): CMdS, GHS, Facets
• Reference code/data sets required for claims adjudication
• Configuring benefits/programs across claims subsystems
• Validate and analyze backend data; perform SQL validation

Requirements

• 8+ years of health care experience, specifically in the MMIS domain
• Strong knowledge of Medicaid and Medicare
• Hands-on experience with claims processing and adjudication
• Experience with reference code/data sets used in claims adjudication
• Ability to run queries and perform basic system analysis and RCA
• Understanding of configuration of benefits/programs across various claims subsystems
• Excellent written and spoken communication
• Ability to multitask between internal teams and clients by priority

Preferred Skills

• Ability to validate test scenarios, test plans, and test data
• Create and maintain Requirements Traceability Matrix (RTM)
• Assess current product functionality vs market trends and regulatory requirements for future versions
• Experience validating EDI X12 files and interface testing (understanding data flow and formats)
• Familiarity with EDI tools and interface testing; tools such as Postman

Work Arrangement

• Remote work (work from home)