Senior Business Analyst – Claims module

Conduent•Gates, NY

3d•$85,470 - $111,000

About The Position

Play the role of Claims Domain lead for MMIS health care projects. Drive the claims module and process, domain knowledge, perform analysis of business requirements, designs and develop documentation, ensures quality process, coordinates with customers. Works in team environment and provides guidance throughout the entire life cycle. Responsible to meet customer expectations, troubleshoot problems in the application and assisting customers in implementation decisions.

Requirements

Strong health care domain experience and good knowledge of Medicaid and Medicare.
Hands-on experience on claims processing and Adjudication processes.
Good experience in Reference code/data sets required in Claims adjudication.
Prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
Ability to run queries and perform basic system analysis, RCA etc.
Excellent written and spoken communication skills.
Ability to multitask between internal team and clients based on priority tasks.
In depth understanding of Claims and Claims lifecycle: Member, Provider, Claim submission – Paper and EDI X12, Adjudication, Payment Cycle (Finance), Reporting.
Knowledge of Claim Types: Professional, Dental, Institutional, Pharmacy, Encounters and Capitation.
Knowledge of Claim Formats: EDI X12 formats like 837P/I/D, X12 formats 835, 834, 270/271, 276/277.
Familiarity with systems like CMdS, GHS, Facets and etc.
SQL: To validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan).
EDI Tools: Validating X12 files.
Interface Testing: Understanding how data flows between systems and formats and use tools like postman.
Minimum of 8+ years of experience in health care especially in MMIS domain.
Capability to think out-of-the-box to create new solutions as needed.
Ability to validate Test scenarios and test plans, test data.
Ability to Review requirements, documentation and create Requirements Traceability matrix (RTM).
Excellent communication (written and spoken ) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units.

Responsibilities

Drive the claims module and process, domain knowledge, perform analysis of business requirements, designs and develop documentation, ensures quality process, coordinates with customers.
Provide guidance throughout the entire life cycle.
Meet customer expectations, troubleshoot problems in the application and assisting customers in implementation decisions.
Work closely with the client and development team during the stages of development, and conduct demos at completion of milestones, track and close feedback from such demos.
Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
Assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product.
Drive and share the requirements with Technical and Architects regarding product features to be implemented.
Collaborate with cross-functional teams.