Job Description

We are seeking an experienced Business Analyst with extensive expertise in the Healthcare Payer domain to join our team as an SME.

Responsibilities

• Act as a trusted SME for Healthcare Payer processes, policies, regulations, and industry best practices
• Elicit and analyze complex business requirements from cross-functional stakeholders, including payers, providers, and other entities
• Define/Write the functional specifications, process flows, and use cases to guide solution design and delivery
• Collaborate with IT, QA, and business teams to align on project scope, objectives, and deliverables
• Perform gap analyses to pinpoint areas for process optimization and system enhancements
• Participate in workshops and stakeholder meetings to gather insights, validate requirements, and drive alignment
• Translate intricate business processes into clear, actionable technical documentation that can be used by developers
• Provide expert guidance during solution implementation to ensure compliance and alignment with business goals.
• Support stakeholders through training and change management initiatives

Requirements

• Bachelor's degree in Science, or a related field
• Minimum of 5 years of experience within the Healthcare Payer domain
• Deep understanding of payer operations including claims processing, enrolment, member management, provider networks, and benefit administration
• Knowledge of the Business Process, Good Understanding of EDI
• Strong understanding of healthcare data formats, standards, and can map them to CMS and state level reporting needs.
• Knowledge of healthcare regulations and compliance standards (e.g., HIPAA, CMS, ACA)
• Expertise with payer systems such as claims management, enrolment platforms, billing, and provider portals
• Exceptional communication and stakeholder engagement skills, Written and Spoke communication Skills
• Familiarity with Agile and Scrum methodologies
• Proficiency with Business Analysis tools and techniques

Nice to have

• Certified Business Analysis Professional (CBAP)
• Healthcare-specific certifications such as CHC or CPCO