Senior Business Analyst – Claims module

Conduent State Healthcare, LLC•, Remote US

7d•$85,470 - $111,000

About The Position

The Senior Business Analyst serves as the Claims Domain lead for MMIS health care projects. The role drives the claims module and processes, applies domain knowledge, analyzes business requirements, develops designs and documentation, ensures process quality, and coordinates with customers. The analyst works in a team environment, provides guidance throughout the project life cycle, meets customer expectations, troubleshoots application problems, and assists customers with implementation decisions. The position requires strong health care domain experience, particularly in Medicaid and Medicare, and hands-on knowledge of claims processing and adjudication. The analyst works closely with clients, development, architecture, and design teams to define product features, GUI views, and platform requirements; supports development stages and milestone demonstrations; and tracks and closes feedback. The role also involves validating test scenarios, plans, and data; reviewing requirements and documentation; and creating Requirements Traceability Matrices. It includes assessing product functionality against market trends and regulatory requirements and sharing product requirements with technical and architecture teams.

Requirements

At least 8 years of experience in health care, especially in the MMIS domain.
Strong health care domain experience and good knowledge of Medicaid and Medicare.
Hands-on experience with claims processing and adjudication processes.
Experience with reference codes and data sets used in claims adjudication.
Prior experience or understanding of configuring benefits or programs in claims systems across multiple subsystems.
Ability to run SQL queries to validate backend data, including claim status, payment details, members, providers, and benefit plans.
Ability to validate X12 files using EDI tools.
Understanding of interface testing, data flows between systems, and formats; experience using tools such as Postman.
In-depth understanding of the claims lifecycle, including members, providers, paper and EDI X12 claim submissions, adjudication, payment cycles, and reporting.
Knowledge of professional, dental, institutional, and pharmacy claims, as well as encounters and capitation.
Knowledge of EDI X12 formats including 837P/I/D, 835, 834, 270/271, and 276/277.
Familiarity with claims systems such as CMdS, GHS, and Facets.
Ability to think creatively to develop new solutions as needed.
Excellent written and spoken communication skills and ability to engage with varied stakeholders.
Ability to multitask between internal teams and clients based on task priorities.

Responsibilities

Lead the Claims domain for MMIS health care projects and drive the claims module and associated processes.
Analyze business requirements, develop designs and documentation, and ensure quality processes.
Coordinate with customers and provide guidance throughout the project life cycle.
Meet customer expectations, troubleshoot application problems, and assist customers with implementation decisions.
Work with clients and development teams during development stages, conduct milestone demonstrations, and track and close feedback.
Collaborate with development, architecture, and design teams to define GUI views and platform requirements.
Run queries and perform basic system analysis and root cause analysis.
Validate test scenarios, test plans, and test data.
Review requirements and documentation and create Requirements Traceability Matrices (RTMs).
Assess current product functionality against market trends and regulatory requirements for future product versions.
Drive and communicate product feature requirements to technical and architecture teams.
Collaborate and communicate with cross-functional teams, clients, QA and development teams, client end users, and business units.