Business Analyst (Policy remediation)

Role Description

We are seeking an experienced Business Analyst with expertise in policy remediation, medical coding, and healthcare claims systems. This role will serve as a subject matter expert (SME) supporting policy and operational initiatives related to medical coding compliance, claims adjudication, and system change management.

The ideal candidate will leverage deep knowledge of ICD-10, CPT, and HCPCS coding methodologies, as well as Medicaid and payer operations, to ensure alignment between policy updates, coding changes, and system functionality. This position will play a critical role in supporting compliance initiatives, regulatory updates, and business process improvements.

Key Responsibilities:

• Serve as a subject matter expert (SME) for medical coding methodologies, Medicaid policy, and claims adjudication processes.
• Analyze annual, quarterly, and ad hoc coding updates, including ICD-10, CPT, and HCPCS changes.
• Review and assess the impact of coding and policy changes on business processes, system functionality, and claims outcomes.
• Collaborate with business stakeholders, policy teams, and technical teams to define requirements and implement necessary system changes.
• Support change requests and ensure system updates produce accurate and expected claims adjudication results.
• Research business rules, requirements, and process models to develop recommendations and solutions.
• Maintain and update business rules, requirements documentation, and process models in designated repositories.
• Lead meetings with stakeholders, business owners, and cross-functional teams.
• Participate in policy remediation efforts, compliance initiatives, and related enterprise projects.
• Ensure process documentation, training materials, and supporting documentation are complete and up to date.
• Collaborate with internal teams to support ongoing operational and regulatory compliance.
• Provide expertise in medical coding software, claims systems, and healthcare policy interpretation.

Qualifications

• Minimum of 5 years of experience in healthcare insurance, medical review, program integrity, or appeals.
• At least 5 years of experience working with IT developers and programmers in a payer environment.
• Minimum of 5 years of hands-on experience in medical coding within a payer environment.
• Strong expertise in ICD-10, CPT, and HCPCS coding methodologies and translation.
• Minimum of 5 years of experience with medical claims processing systems.
• Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint).
• Experience using Optum Encoder or similar medical coding software.
• Strong analytical, problem-solving, and critical-thinking skills.
• Excellent written and verbal communication skills.

Requirements

• Minimum of 5 years of experience in policy remediation.
• At least 3 years of clinical experience in a healthcare environment.
• Strong clinical assessment and critical-thinking skills.
• Experience with Medicaid programs and Medicaid Management Information Systems (MMIS).
• Familiarity with healthcare regulatory compliance and policy implementation.

Technical Skills

• Medical Coding and Reimbursement
• ICD-10, CPT, and HCPCS Expertise
• Policy Remediation and Compliance
• Claims Adjudication and Processing
• Medicaid and MMIS Knowledge
• Business Requirements Analysis
• Process Documentation and Improvement
• Stakeholder Engagement and Facilitation
• Regulatory and Operational Compliance
• Cross-Functional Collaboration

Education

• Bachelor’s degree in Health Information Management, Healthcare Administration, Business, or a related field.