Business Analyst

Analyze the end-to-end claims lifecycle (intake → EDI → edits → pend resolution → adjudication → pricing → COB → payment → remittance) and drive gap closure and automation. Elicit and document business/functional requirements for claims adjudication, pricing, and payment systems — BRDs, FRDs, user stories with acceptance criteria, business rules, and traceability matrices.

Our Client, an IT Services and Consultant company, is looking for a Business Analyst for their Remote location.
 
Responsibilities:

• Elicit and document business/functional requirements for claims adjudication, pricing, and payment systems — BRDs, FRDs, user stories with acceptance criteria, business rules, and traceability matrices.
• Analyze the end-to-end claims lifecycle (intake → EDI → edits → pend resolution → adjudication → pricing → COB → payment → remittance) and drive gap closure and automation.
• Own FEP-specific requirements: FEP Direct/Express workflows, FEP Blue Standard/Basic/Focus benefit structures, annual brochure benefit changes, and FEP Operations Center files and reporting.
• Translate OPM/FEHB guidance and carrier letters into system requirements and configuration change requests.
• Perform source-to-target data mapping for X12 transactions (837, 835, 834, 270/271, 276/277, 278) and proprietary claim layouts.
• Document and validate claims business rules: accumulators, benefit limits, authorization matching, timely filing, duplicate logic, contract pricing, and edit dispositions.
• Write SQL to profile claims data, validate adjudication outcomes, and perform root-cause analysis on production defects.
• Define test scenarios and lead SIT/regression/UAT cycles, defect triage, and business sign-off.
• Lead requirements for mandate and regulatory releases (CMS updates, No Surprises Act, annual ICD-10/CPT/HCPCS code updates).
• Support production escalations: payment discrepancies, adjustments/voids, overpayment recovery, provider/member issues.
• Drive Agile ceremonies with the Product Owner — backlog grooming, prioritization, sprint planning, reviews.
• Prepare audit deliverables for internal, OPM, and CMS reviews; mentor junior analysts and act as claims/FEP domain SME.

 
Requirements:

• Bachelor's degree in IT, Computer Science, Health Informatics, Business, or related field.
• 8+ years as an IT/Business Systems Analyst in the healthcare payer domain.
• 5+ years hands-on with claims processing and adjudication systems.
• 3+ years direct FEP claims processing experience — FEP Direct/Express, FEP Blue plan structures, OPM/FEHB rules, FEP reporting cycles.
• Hands-on experience with an enterprise claims platform: Facets, QNXT, HealthEdge HealthRules, NASCO, Amisys, or equivalent.
• Working knowledge of HIPAA X12 5010 transactions: 837, 835, 834, 270/271, 276/277, 278.
• Knowledge of ICD-10, CPT, HCPCS, DRG, revenue codes, modifiers, NDC, NPI, CMS-1500, UB-04.
• Experience with COB/TPL, Medicare crossover, and subrogation rules.
• Intermediate-to-advanced SQL for data analysis and validation.
• Proven Agile/Scrum delivery experience with Jira, Azure DevOps, or Rally.
• Strong process modeling skills (Visio, Lucid chart, BPMN) and audit-ready documentation discipline.
• Solid HIPAA privacy/security and PHI handling knowledge.
• Experience using AI-assisted tooling (Copilot, Devin, Windsurf) for requirements, test case generation, and spec-driven documentation.
• Preferred Qualifications
• BCBS plan experience, including Inter-Plan/ITS BlueCard host-home claims flows.
• Claims platform implementation, conversion, or migration experience.
• Provider contract configuration, fee schedules, and repricing logic.
• Payment integrity tools (Optum CES, ClaimsXten) and EDI gateways (Edifecs, Availity, TriZetto).
• Medicare Advantage, Medicaid, or ACA/Marketplace claims exposure.
• Cloud/data platforms (AWS, Azure, Snowflake) and BI tools (Power BI, Tableau).
• RPA for claims operations (UiPath, Automation Anywhere).
• Certifications: CBAP, PMI-PBA, CSPO/SAFe POPM, AHIP, or AAPC/AHIMA coding credentials.
• Technical Skills
• Domain
• Claims adjudication, pricing, payment, and remittance
• FEP claims processing (FEP Direct/Express, OPM/FEHB rules)
• Benefit administration, accumulators, COB/TPL, overpayment recovery
• Regulatory: HIPAA, ACA, No Surprises Act, CMS mandates
• Platforms
• Facets / QNXT / HealthEdge HealthRules / NASCO / Amisys
• FEP Direct / FEP Express
• Optum CES / ClaimsXten
• EDI & Integration
• X12 5010 (837, 835, 834, 270/271, 276/277, 278), NCPDP
• CMS-1500, UB-04, flat file, XML, JSON, REST APIs
• Data & Reporting
• SQL (Oracle, SQL Server, DB2, PostgreSQL)
• Advanced Excel, data mapping and reconciliation
• Power BI / Tableau; Snowflake (preferred)
• Tools & Methods
• Jira, Azure DevOps, Confluence, Visio, Lucid chart
• qTest / Zephyr / ALM for test and defect management
• Agile, Scrum, SAFe; AI-assisted spec-driven analysis
• Additional Information:
• Ability to work independently with minimal support
• Follow Best practices while coding.
• Ability to work with diverse group of stakeholders and integration teams to complete the work.
• Years of Experience:  
• 8.00 Years of Experience

 
Why Should You Apply?

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities