Business Analyst - Self-Funded & Payor Operations

Business Analyst – Self-Funded & Payor Operations | Coppell, TX We are seeking a Business Analyst with strong hands-on experience in self-funded health plan operations, TPA/payor workflows, claims administration, and benefits technology. This role is ideal for someone who understands how self-funded and level-funded plans are structured, administered, and supported across claims, eligibility, enrollment, stop-loss, compliance, and employer group operations. Key Responsibilities: Gather, analyze, and document business and functional requirements for self-funded and level-funded health plan administration. Translate plan documents, SPDs, benefit schedules, funding arrangements, and employer requirements into clear operational and system requirements. Document claims workflows including intake, pricing, adjudication, COB, subrogation, repricing, EOB generation, and payment release. Support requirements for specific and aggregate stop-loss tracking, large claimant reporting, lasering, reimbursement workflows, and carrier coordination. Map end-to-end TPA/payor workflows including eligibility, enrollment, benefit configuration, utilization management, case management, appeals, grievances, billing, and reporting. Partner with operations, product, technology, employer clients, brokers, and vendor partners to improve processes and support platform enhancements. Develop user stories, BRDs, functional specifications, process flows, UAT scenarios, and reporting requirements. Ensure requirements align with ERISA, ACA, HIPAA, COBRA, MHPAEA, and applicable healthcare regulations. Required Skills: 5+ years of Business Analyst or operations experience in self-funded health plans, TPAs, ASO models, stop-loss carriers, or payor environments. Strong understanding of plan documents, SPDs, benefit schedules, funding arrangements, specific and aggregate stop-loss, run-in/run-out periods, and terminal liability. Hands-on knowledge of claims adjudication, COB, subrogation, repricing, network contract application, payment integrity, and EOB generation. Experience with claims management systems, benefits administration platforms, or TPA technology platforms. Strong analytical skills with experience reviewing claims data, utilization reports, lag reports, large claimant reports, and stop-loss tracking. Ability to work directly with employers, brokers, executives, operations teams, and technical teams. Strong documentation, communication, process mapping, and stakeholder management skills. Preferred Skills: Experience with TPA implementations, renewals, plan year changes, open enrollment, and employer group onboarding. Knowledge of PBM integrations, reference-based pricing, direct contracting, provider networks, alternative funding, COBRA, HRA/HSA/FSA, and EDI transactions including 837, 835, 270, 271, and 278. Agile/Scrum, Jira, Confluence, CEBS, CBAP, or PMI-PBA experience is a plus. Location: Coppell, TX Work Model: Full-Time Onsite Role: Business Analyst – Self-Funded & Payor Operations