Business Analyst

Business Analyst

This Business Analyst role interprets regulatory and business requirements and translates them into actionable edit configurations within pre-pay platforms. This role partners with Payment Integrity, Health Plans, IT, vendors, and SMEs to ensure accurate implementation and optimization of claims editing solutions. The position requires strong ownership, advanced analytical skills, and hands-on validation of rule-based logic to ensure alignment with business intent and financial outcomes. It also supports system development, maintenance, and applicable governance activities.

Job Duties

• Lead interpretation of state, CMS, and health plan requirements and translate them into business rules, edit logic, configuration strategies, and supporting documentation
• Own the full lifecycle of edit development, including requirements intake, configuration, validation, deployment, and ongoing maintenance
• Review, validate, and refine rule-based logic or code to ensure accuracy, completeness, and alignment with regulatory and business intent
• Partner with IT, vendors, and cross-functional teams to ensure successful deployment, issue resolution, and alignment on requirements and solutions
• Lead working sessions, governance processes, and interpretation reviews to drive cross-functional clarity and maintain traceability from requirement to outcome
• Monitor regulatory sources and system updates to ensure consistent alignment with coverage, reimbursement, and processing requirements
• Perform advanced root-cause analysis on logic gaps, configuration defects, performance issues, and state-requirement-related problems
• Communicate requirement interpretations, changes, and impacts to health plans, product teams, and core functional areas

Job Qualifications

Required Qualifications

• 3+ years of experience in healthcare, managed care, or Payment Integrity, with strong knowledge of claims adjudication, claims editing, reimbursement logic, and related platforms
• Proven ability to interpret, review, and validate rule-based logic or configuration outputs, and synthesize complex requirements into clear business and configuration direction
• Strong analytical, problem-solving, and critical-thinking skills, including the ability to manage multiple states, lines of business, and aggressive timelines
• Effective communicator with experience leading requirement discussions, influencing cross-functional teams, and organizing regulatory data and real-time policy updates
• Ability to work independently in a remote environment, collaborate across time zones, and utilize Microsoft Office tools (Word, Excel, Outlook, Teams) proficiently

Preferred Qualifications

• Familiarity with structured logic, scripting, or rule-based configuration tools
• Knowledge and experience with federal regulatory policy resources, including Centers for Medicare & Medicaid Services (CMS), the Affordable Care Act (ACA), and Medicaid state requirements
• Experience developing and maintaining requirement documents related to edit configurations
• Experience conducting analysis to identify root cause and support problem management related to state requirements
• Experience leading UAT, validation cycles, and production deployments
• Medical coding knowledge (CPT/HCPCS/ICD) or coding certification