Healthcare Claims Business Analyst/SME
Core
Subject matter expert on healthcare claims operations, EDI standards, and payer adjudication logic, serving as the bridge between client payer workflows and implementation teams.
Role type
Senior IC Healthcare Claims Business Analyst
Builds
Implementation of claims intake, adjudication rules, coordination of benefits, appeals, and remittance processes on the Incedo claims platform for healthcare payers.
Domain
Healthcare Payer / Insurance Claims / Health Information Management
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
Healthcare claims operations, HIPAA X12 EDI transactions (834, 837P/I/D, 835, 270/271, 275, 276/277, 278), claims adjudication platforms, clearinghouse partnerships, payer-side EDI trading partner onboarding, ICD-10, CPT, HCPCS Level II, revenue codes, NCCI edits, software rollouts, system migrations, business analysis, workflow mapping, gap analysis, BRD creation, functional specifications, data mapping, UAT coordination, CMS rules, HIPAA standards, state Medicaid requirements, electronic prior authorization, No Surprises Act, SQL.
Preferred skills
Medicare Advantage or Medicaid managed care claims operations, CMS encounter data submission, CMS-0057-F electronic prior authorization, No Surprises Act dispute resolution, utilization management, care management platforms, CPHQ, RHIT, RHIA, PMP, SQL proficiency for data validation.
Technologies
Incedo claims platform, CMS, SQL, X12 EDI standards, clearinghouse systems.
Responsibilities
Translate client payer workflows into business and functional specifications; advise on configuring claims intake, adjudication rules, COB, appeals, and remittance; identify and document gaps between legacy processes and platform capabilities; support claims data migration planning and legacy crosswalks; lead business analysis during onboarding including discovery and gap analysis; create BRDs, functional specs, and EDI companion guides; coordinate end-to-end transaction testing and UAT; record configurations and edge cases; mentor junior staff on claims concepts and EDI troubleshooting; relay enhancement requests to Product and Engineering; stay current on CMS rules and X12 standards; build internal training materials.
Seniority
Senior, hands-on IC
