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
