Business Systems Analyst Healthcare Payer (Actuarial / Underwriting / HEDIS)

STAFFXPERT LLC is seeking a Business Systems Analyst Healthcare Payer on behalf of our client in a remote setting. The ideal candidate will bring strong healthcare payer domain expertise along with hands-on data analysis experience and a solid understanding of Actuarial, Underwriting, and HEDIS/Quality functions .

This role will bridge healthcare business processes and data, helping stakeholders understand how information moves across systems, validating business rules and metrics, and translating complex business knowledge into clear, well-defined data and process documentation.

• Analyze healthcare payer business processes, systems, data architecture, and end-to-end data flows.

• Work across Actuarial, Underwriting, HEDIS/Quality, Claims, Membership, Provider, Premium, and Cost/Utilization domains.

• Partner with business SMEs and technical teams to understand and document business rules, calculations, metrics, assumptions, and dependencies.

• Analyze and validate healthcare metrics, including PMPM, utilization, allowed/paid amounts, member months, IBNR, risk adjustment, MLR, and HEDIS measures .

• Perform data profiling, reconciliation, validation, and analysis to identify gaps, inconsistencies, and undocumented business rules.

• Reverse-engineer business logic and data flows from existing applications, datasets, queries, and processes.

• Translate business concepts into data definitions, mappings, semantic models, and business rules .

• Collaborate with architects, data engineers, analysts, and healthcare SMEs to capture and document institutional knowledge.

• Support analytics and emerging AI/data-driven initiatives by ensuring healthcare data has appropriate business context, definitions, relationships, and validation.

• 8 10+ years of relevant experience in healthcare business analysis, data analysis, or consulting.

• Strong healthcare payer domain experience with practical knowledge of Actuarial, Underwriting, and HEDIS/Quality functions.

• Strong understanding of healthcare cost and utilization concepts, including PMPM, utilization, allowed/paid amounts, member months, IBNR, trend, risk adjustment, and MLR .

• Experience working with healthcare payer data domains such as claims, membership/enrollment, provider, premium, clinical/quality, and cost/utilization data .

• Strong understanding of data lineage, system architecture, upstream/downstream dependencies, and end-to-end data flows .

• Strong SQL and data analysis skills with experience working with complex datasets.

• Experience with data profiling, reconciliation, validation, mapping, and business-rule discovery .

• Ability to reverse-engineer business logic from data, applications, queries, and SME discussions.

• Experience documenting business definitions, data rules, mappings, assumptions, and process/data flows .

• Excellent analytical, problem-solving, communication, and stakeholder-management skills.

• Experience working within a health plan or on healthcare payer transformation, analytics, or data modernization initiatives.

• Experience with Snowflake or comparable cloud data platforms.

• Exposure to semantic modeling, metadata management, business glossaries, or enterprise data models .

• Experience with AI-enabled analytics, data agents, or natural-language-to-data solutions.

• Experience integrating data across multiple healthcare business functions.