Senior Business Analyst with Claims - Remote with Travel

1. Candidate should have strong health care domain experience and should have good knowledge of Medicaid and Medicare.

• 2. Candidate should have hands-on experience on claims processing and Adjudication processes.
• 3. Must have good experience in Reference code/data sets required in Claims adjudication.
• 4. Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
• 5. Should be able to run queries and perform basic system analysis, RCA etc.,
• 6. Should work closely with the client and development team during the stages of development, and conduct demos at completion of milestone, track and close feedback from such demos
• 7. Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks
• 8. Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
• 9. In depth understanding of Claims and Claims lifecycle:
• Member
• Provider
• Claim submission - Paper and EDI X12
• Adjudication
• Payment Cycle (Finance)
• Reporting
• 10. Claim Types:
• Professional
• Dental
• Institutional
• Pharmacy
• Encounters and Capitation
• 11. Claim Formats:
• EDI X12 formats like 837P/I/D
• X12 formats 835, 834, 270/271, 276/277
• 12. Claim System:
• Familiarity with systems like CMdS, GHS, Facets and etc
• Technical Skills
• SQL: To validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan).
• EDI Tools: Validating X12 files.
• Interface Testing: Understanding how data flows between systems and formats and use tools like postman
• Preferred skills:
• Minimum of 8+ years of experience in health care experience especially in MMIS domain.
• Capability to think out-of-the-box to create new solutions as needed.
• Ability to validate Test scenarios and test plans, test data.
• Should be able to Review requirements, documentation and create Requirements Traceability matrix (RTM)
• Should have excellent communication (written and spoken ) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units.
• Ability to assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product.
• Ability to drive and share the requirements with Technical and Architects regarding
• product features to be implemented.
• Communication: Collaborate with cross-functional teams