Your Role
The Clinical Coding team seeks an experienced Business Analyst, Consultant with strong analytical, business, and technical expertise to support complex, cross functional initiatives. This role is responsible for analyzing data, defining business requirements, and driving operational improvements related to payment policy, medical policy, and coding related processes, while also contributing to the development of annual operating plans, budgets, forecasts, and cost/benefit analyses for new initiatives. The Business Analyst, Consultant will report to the Sr. Manager, Clinical Coding. In this role, you will play a critical role in ensuring payment and medical policy logic is accurately translated into system configuration, directly impacting claims accuracy, regulatory compliance, and cost of healthcare outcomes, while influencing cross-functional decision-making through expert analysis and identification of improvement opportunities.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Knowledge and Experience
Requires a bachelor's degree or equivalent experience
Requires at least 7 years of prior relevant experience
Requires deep knowledge of job area typically obtained through advanced education combined with experience.
Requires strong knowledge of business analysis, payment policy, California state mandates and claims operations
Requires at least 3 years of Payment policies and claims processing or equivalent experience
Familiarity with provider manuals, CMS/NCCI guidelines, and payment integrity operations
Requires knowledge of ClaimsXten or similar claims editing software
Strong analytical and problem-solving skills with ability to conduct independent research and synthesize findings
Advanced knowledge and ability to perform process mapping, root-cause analysis, gap analysis and requirements gathering
Requires practical knowledge of project management
Ability to deal with complexity, compressed timelines and shifting priorities
Proficient with MS Office products, including Word, PowerPoint and Excel. Visio expertise a plus
Strong interpersonal and verbal and written communication skills.
Agile experience preferred
Hybrid
This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
Your Work
In this role, you will:
Provide highly complex analytical support through the analysis and interpretation of data in support of cross-functional business operations
Lead the development of annual operating plans, capital budgets and forecasts, and build business cases for new business initiatives (cost/benefit analysis)
Develop, prepare, and analyze reports with highly complex analysis and data for management review, and presents to various levels of management
Define business requirements and provide analysis to increase operational efficiency
Support multiple, highly complex cross-functional projects simultaneously by establishing work plans, managing timelines, and coordinating with internal and external stakeholders
Manage critical programs including ClaimsXten monthly maintenance, release planning, and defect resolution to ensure accurate and timely claims adjudication
Translate payment policy, regulatory requirements (e.g., CMS, NCCI), and medical policy intent into system configuration and business rules
Partner cross-functionally with Payment Integrity, IT, Medical Policy, and Operations teams to design and implement business solutions
Monitor operational performance and identify risks, gaps, and improvement opportunities to support cost of healthcare (CoHC) outcomes
Support audit readiness, compliance requirements, and provider dispute resolution through data analysis and documentation
Your Work
In this role, you will:
Provide highly complex analytical support through the analysis and interpretation of data in support of cross-functional business operations
Lead the development of annual operating plans, capital budgets and forecasts, and build business cases for new business initiatives (cost/benefit analysis)
Develop, prepare, and analyze reports with highly complex analysis and data for management review, and presents to various levels of management
Define business requirements and provide analysis to increase operational efficiency
Support multiple, highly complex cross-functional projects simultaneously by establishing work plans, managing timelines, and coordinating with internal and external stakeholders
Manage critical programs including ClaimsXten monthly maintenance, release planning, and defect resolution to ensure accurate and timely claims adjudication
Translate payment policy, regulatory requirements (e.g., CMS, NCCI), and medical policy intent into system configuration and business rules
Partner cross-functionally with Payment Integrity, IT, Medical Policy, and Operations teams to design and implement business solutions
Monitor operational performance and identify risks, gaps, and improvement opportunities to support cost of healthcare (CoHC) outcomes
Support audit readiness, compliance requirements, and provider dispute resolution through data analysis and documentation