Business Analyst
ICONMA
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
Vacancy posted 2 days ago
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