Claims Module Senior Business Analyst

Conduent • Gates, NY

1d • $85,470 - $111,000 • Remote

About The Position

This individual will play the role of Claims Domain lead for MMIS health care projects.

Requirements

• Candidate should have strong health care domain experience and should have good knowledge of Medicaid and Medicare.
• Candidate should have hands-on experience on claims processing and Adjudication processes.
• Must have good experience in Reference code/data sets required in Claims adjudication.
• Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
• Should be able to run queries and perform basic system analysis, RCA etc.,
• Should 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
• Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks
• Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
• In depth understanding of Claims and Claims lifecycle: Member, Provider, Claim submission – Paper and EDI X12, Adjudication, Payment Cycle (Finance), Reporting
• Claim Types: Professional, Dental, Institutional, Pharmacy, Encounters and Capitation
• Claim Formats: EDI X12 formats like 837P/I/D, X12 formats 835, 834, 270/271, 276/277
• Claim System: 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

Nice To Haves

• Minimum of 8+ years of experience in health care experience 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.
• Should be able to Review requirements, documentation and create Requirements Traceability matrix (RTM)
• Should have excellent communication (written and spoken) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units.
• Ability to assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product.
• Ability to drive and share the requirements with Technical and Architects regarding product features to be implemented.
• Communication: Collaborate with cross-functional teams

Responsibilities

• Drive the claims module and process and provide domain knowledge
• Perform analysis of business requirements
• Design and develop documentation and ensure quality process while coordinating with customers.
• Work in a team environment and provide guidance throughout the entire life cycle.
• Responsible for meeting customer expectations and troubleshooting problems in the application.
• Assist customers in implementation decisions.

Benefits

• health insurance coverage
• voluntary dental and vision programs
• life and disability insurance
• a retirement savings plan
• paid holidays
• paid time off (PTO) or vacation and/or sick time

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed