Senior Business Analyst - Claims Configuration

Gainwell Technologies LLC•Any city, OH

25d•$92,900 - $132,700•Remote

About The Position

As an Senior Business Analyst - Claims Configuration at Gainwell, you will provide senior functional and technical expertise for Medicaid claims configuration within a Maintenance & Operations environment. You will translate client requirements, Medicaid policy, operational needs, and claims-processing outcomes into scalable QNXT configuration solutions while leading a team of Configuration Business Analysts.

Requirements

9+ years of hands-on, highly proficient QNXT configuration experience, with demonstrated depth in contracts, benefits, fee schedules and multiple payment methodologies, capitation, rules, successful data points for X12 transactions, and CARC/RARC processing.
Thorough understanding of relational database concepts, healthcare data models, schemas, keys, and data relationships.
Demonstrated competency writing complex SQL queries for claims analysis, validation, troubleshooting, root cause analysis, and reporting.

Nice To Haves

Strong experience with Medicaid claims processing, claims adjudication, provider reimbursement, benefits, and encounter processing.
Experience analyzing healthcare transactions (837/835), claims data, and remittance information.
Proven ability to troubleshoot complex claims issues, identify root causes, and implement effective solutions.
Experience leading or mentoring analysts and collaborating with clients, stakeholders, and cross-functional teams.
Knowledge of Agile/SDLC environments and healthcare industry regulations, policies, and compliance requirements.

Responsibilities

Lead, mentor, and provide day-to-day technical direction to a team of Claims Configuration Business Analysts.
Serve as the senior configuration subject matter expert and trusted advisor for assigned CEF Claims M&O accounts.
Review configuration analysis, solution designs, implementation plans, and validation results for quality, accuracy, and downstream impact.
Establish consistent configuration practices, documentation standards, peer-review controls, and knowledge-transfer processes.
Interact directly with clients, vendors, and internal business, product, development, testing, operations, finance, provider, member, and encounter teams.
Lead requirements discussions, configuration reviews, issue-resolution sessions, defect triage, solution walkthroughs, and operational governance discussions.
Translate complex technical findings into clear business impacts, options, risks, and recommendations for stakeholders and leadership.
Own assigned issues and enhancements from intake and analysis through implementation, validation, communication, and closure.
Configure and support QNXT claims solutions across contracts, benefits, fee schedules, payment methodologies, capitation, business rules, claims adjudication logic, X12 transaction data requirements, and CARC/RARC processing.
Translate Medicaid policy, contractual requirements, and operational needs into configuration specifications, business rules, design artifacts, and acceptance criteria.
Assess the full impact of proposed changes across claims adjudication, pricing, benefits, provider reimbursement, encounters, remittance, financial processing, reporting, and downstream integrations.
Determine whether an issue is caused by configuration, data, policy interpretation, user processing, interface behavior, product functionality, or another upstream or downstream dependency.
Write and execute complex SQL queries to analyze claims, claim lines, provider affiliations, contracts, benefits, pricing, member eligibility, edits, accumulators, encounters, and financial data.
Use relational database schemas and data relationships to trace system behavior and validate claims-processing outcomes.
Perform claim-level and population-level root cause analysis for denials, pends, unexpected edits, underpayments, overpayments, duplicate conditions, encounter rejections, and other processing anomalies.
Quantify impacted claims and populations, document evidence, compare expected and actual results, and recommend sustainable corrective actions.
Support production incidents, client inquiries, audit requests, configuration defects, data fixes, and ad hoc reporting needs.
Validate configuration changes through targeted data analysis, claims testing, regression review, and post-implementation monitoring.