Claims SME / Business Analyst

Job Title: Claims SME / Business Analyst (Healthcare)

Location: Minnetonka, MN



Work Model: Hybrid



Employment Type: Full-Time / Contract



Experience: 10+ Years



Domain: U.S. Healthcare Claims, Payment Integrity Job Description

We are seeking an experienced Claims Subject Matter Expert (SME) / Business Analyst (BA) with strong U.S. healthcare domain knowledge and expertise in claims lifecycle, claims adjudication, and payment integrity. The ideal candidate will bridge the gap between business stakeholders, technology teams, data science, and analytics teams to deliver business solutions, improve operational efficiency, and support AI-driven automation initiatives.

Key Responsibilities

Business Analysis & Solution Design

• Gather, analyze, and document complex business and system requirements.
• Translate business needs into functional requirements, user stories, workflows, and process models.
• Facilitate requirements-gathering workshops with business and technology stakeholders.
• Support solution design, implementation, UAT, and end-to-end delivery.
• Validate solutions against business requirements and acceptance criteria.

Healthcare Claims & Payment Integrity

• Analyze healthcare claims, provider billing patterns, member utilization, and payment integrity opportunities.
• Demonstrate strong knowledge of the end-to-end healthcare claims lifecycle and claims adjudication.
• Identify improper payments, financial leakage, process gaps, and opportunities for cost optimization.
• Collaborate with healthcare SMEs to evaluate clinical and non-clinical claims scenarios.
• Perform root cause analysis and recommend process improvements.
• Support initiatives related to Fraud, Waste, and Abuse (FWA), payment integrity, and revenue cycle management.

AI & Intelligent Automation

• Translate business challenges and risks into AI-ready business requirements.
• Define business rules, thresholds, indicators, and intervention logic for AI-enabled workflows.
• Partner with data science and analytics teams to define model inputs, outputs, validation criteria, and success metrics.
• Support human-in-the-loop review processes and AI governance.
• Contribute to intelligent automation and decision-support initiatives.
• Ensure AI-driven solutions are explainable, auditable, and aligned with business objectives.

Data Analysis & Reporting

• Analyze large healthcare datasets to identify trends, anomalies, and improvement opportunities.
• Collaborate with analytics teams to define KPIs, metrics, and reporting requirements.
• Support data validation, business testing, and UAT activities.
• Use data-driven insights to support business decisions and process improvements.
• Leverage SQL for data analysis and validation.

Stakeholder Management

• Act as a liaison between business operations, product, engineering, data science, and analytics teams.
• Facilitate stakeholder discussions, solution reviews, and alignment sessions.
• Present findings, recommendations, and business insights to stakeholders and leadership.
• Drive consensus across cross-functional teams.

Required Qualifications

• 10+ years of experience in Business Analysis or Business Systems Analysis.
• Strong U.S. healthcare domain experience across multiple lines of business.
• Mandatory knowledge of the end-to-end healthcare claims lifecycle.
• Strong understanding of healthcare claims processing and adjudication.
• Experience in claims management, payment integrity, and/or healthcare operations.
• Experience gathering requirements, documenting business processes, and translating business needs into functional specifications.
• Strong stakeholder management, communication, analytical, and problem-solving skills.
• Experience working in Agile delivery environments.
• SQL and data analysis experience.

Preferred Qualifications

• Experience in Payment Integrity, Fraud, Waste, and Abuse (FWA), or Revenue Cycle Management.
• Exposure to AI, machine learning, advanced analytics, or intelligent automation initiatives.
• Experience working with Databricks, Snowflake, Tableau, or Power BI.
• Experience defining business rules, validating analytical models, and supporting data-driven healthcare solutions.
• Experience with UAT, process improvement, and cross-functional project delivery.

Work Authorization

Candidates authorized to work in the U.S. will be considered, subject to applicable employment and client requirements. H-1B candidates may be considered for contract opportunities, subject to client approval

Ideal Candidate Profile

A seasoned healthcare Business Analyst or Claims SME with strong claims lifecycle knowledge, hands-on business analysis experience, and the ability to collaborate with technical and analytics teams on payment integrity, data-driven decision-making, and AI-enabled healthcare solutions.