Business Systems Analyst (Healthcare Payer COB SME)

Senior Business Systems Analyst (Healthcare Payer COB SME)

Location- United States (Onshore EST preferred)

Experience

15+ years of overall Business Analysis experience with 10+ years focused on Healthcare Payer operations and at least 7+ years in Coordination of Benefits (COB), Eligibility, Enrollment, and Member Data Management domains.

Key Highlights:

Deep knowledge of: Coordination of Benefits (COB)

Direct AI experience along with BSA skills is the separator.

Need to have client facing experience and open to "occasional" travel to DC

Position Summary

We are seeking a highly experienced and strategic Senior Business Systems Analyst (BSA) with deep expertise in Coordination of Benefits (COB), Payer Operations, Eligibility & Enrollment, Primacy Determination, EMPI, and Healthcare Interoperability , combined with demonstrated experience leveraging AI-enabled delivery, Agentic AI platforms, Generative AI tools, and AI-assisted SDLC methodologies to accelerate business transformation initiatives.

The ideal candidate will serve as the primary bridge between business stakeholders, product leadership, operations teams, and engineering teams during the modernization of a large-scale COB platform. This individual will lead business discovery, rule rationalization, requirements engineering, data analysis, and operational transformation initiatives while ensuring business outcome parity with legacy COB platforms.

The role requires a combination of strong healthcare domain expertise, exceptional analytical capabilities, stakeholder management skills, and the ability to translate complex COB business processes into scalable technology solutions.

Key Responsibilities

COB Domain Leadership

• Act as the SME for Coordination of Benefits operations, payer enrollment processing, primacy determination, overlap management, and member eligibility workflows.
• Lead workshops with payer operations, business users, product owners, and executive stakeholders.
• Analyze and rationalize existing COB business processes and operational workflows.
• Interpret and document NAIC COB guidelines, Medicare Secondary Payer (MSP) rules, Medicaid regulations, and state-specific COB requirements.
• Drive business rule governance and establish traceability from regulations to platform implementation.
• Define future-state business capabilities for modernized COB ecosystems

Requirements & AI-assisted Business Analysis

• Conduct current-state and future-state assessments.
• Facilitate business process modeling, gap analysis, and impact assessments.
• Develop BRDs, FRDs, user stories, use cases, process flows, and acceptance criteria.
• Translate complex business requirements into epics, features, and detailed user stories.
• Manage requirements traceability throughout the SDLC.
• Define MVP scope and release-level business priorities.
• Leverage Generative AI platforms (ChatGPT, Claude, Copilot, Gemini, etc.) to accelerate:
  • Requirement elicitation
  • User story generation
  • Process documentation
  • Acceptance criteria creation
  • Test scenario generation
  • Business rule extraction
• Utilize AI-assisted analysis techniques to reverse engineer legacy COB applications and uncover hidden business logic.

Legacy Modernization & Rule Engineering

• Reverse engineer legacy COB applications, business rules, SQL logic, and operational workflows.
• Collaborate with architects and engineers to modernize legacy COB functionality into cloud-native services.
• Map legacy business rules into configurable rule engines.
• Support outcome parity initiatives by validating that modernized solutions produce equivalent COB outcomes.

Data Analysis & Member Matching

• Analyze large-scale enrollment and eligibility datasets.
• Define business requirements for EMPI and member matching processes.
• Validate deterministic and probabilistic matching outcomes.
• Work with data architects to define business data models, canonical structures, and data quality rules.
• Support reconciliation and data migration activities.

Interoperability & Integration

• Define business requirements for APIs, FHIR-based integrations, and payer interfaces.
• Collaborate with integration teams to document data contracts and interface specifications.
• Support API and SFTP-based business workflows.
• Ensure interoperability requirements align with healthcare standards and payer expectations.

Testing & Validation

• Lead UAT planning and execution.
• Define business validation scenarios and test data requirements.
• Create end-to-end COB business test scenarios.
• Validate primacy determination outcomes, member matching accuracy, and regulatory compliance.
• Support parallel-run and outcome-parity testing activities.

Stakeholder & Program Leadership

• Serve as the trusted advisor to business and operational stakeholders.
• Present requirements, solution options, risks, and recommendations to senior leadership.
• Facilitate decision-making sessions and requirements sign-off workshops.
• Mentor junior analysts and domain consultants.
• Drive cross-functional collaboration across Product, Operations, Engineering, Data, QA, and Program Management teams.

Required Qualifications

Domain Expertise

• Deep knowledge of:
  • Coordination of Benefits (COB)
  • Primacy Determination
  • Enrollment & Eligibility
  • Medicare Secondary Payer (MSP)
  • Medicaid Coordination Rules
  • NAIC COB Guidelines
  • Healthcare Payer Operations
  • Member Matching / EMPI
  • Provider and Payer Ecosystems

Technical & Analytical Skills

• Strong SQL and data analysis capabilities.
• Experience analyzing complex healthcare datasets.
• Familiarity with Azure-based data platforms and modern cloud ecosystems.
• Understanding of API-driven architecture and microservices.
• Hands-on experience with HL7 and FHIR standards.

Business Analysis Skills

• Expert in requirements elicitation and stakeholder management.
• Strong process modeling skills (BPMN, Visio, Lucidchart, etc.).
• Experience working within Agile/Scrum and SAFe delivery models.
• Strong documentation and communication capabilities.

Preferred Qualifications

• Experience supporting large healthcare modernization programs.
• Experience with COB platform implementations or migrations.
• Prior experience working with healthcare clearinghouses, enrollment platforms, or eligibility systems.
• Knowledge of Azure, Databricks, and healthcare data platforms.
• CBAP, PMI-PBA, SAFe BA, or equivalent certifications.
• Experience supporting AI-assisted requirements engineering and business process transformation initiatives.