Business Analyst - Healthcare

Business Analyst
Remote

Rate:$55


What are the top 3 skills required for this role?
Strong expertise in Claims processing
Strong expertise in FEP line of business
Strong System Analyst, business analysis experience in healthcare industry. Healthcare payer domain.


Job Description/ Responsibilities:
BA bridging Claims Operations and IT delivery for a health plan, with deep expertise in claims adjudication and Federal Employee Program (FEP) claims processing. Owns requirements, data mapping, and validation across the claims lifecycle.

Key Responsibilities:
Elicit and document business/functional requirements for claims adjudication, pricing, and payment systems - BRDs, FRDs, user stories with acceptance criteria, business rules, and traceability matrices.
Analyze the end-to-end claims lifecycle (intake EDI edits pend resolution adjudication pricing COB payment remittance) and drive gap closure and automation.
Own FEP-specific requirements: FEP Direct/Express workflows, FEP Blue Standard/Basic/Focus benefit structures, annual brochure benefit changes, and FEP Operations Center files and reporting.
Translate OPM/FEHB guidance and carrier letters into system requirements and configuration change requests.
Perform source-to-target data mapping for X12 transactions (837, 835, 834, 270/271, 276/277, 278) and proprietary claim layouts.
Document and validate claims business rules: accumulators, benefit limits, authorization matching, timely filing, duplicate logic, contract pricing, and edit dispositions.
Write SQL to profile claims data, validate adjudication outcomes, and perform root-cause analysis on production defects.
Define test scenarios and lead SIT/regression/UAT cycles, defect triage, and business sign-off.
Lead requirements for mandate and regulatory releases (CMS updates, No Surprises Act, annual ICD-10/CPT/HCPCS code updates).
Support production escalations: payment discrepancies, adjustments/voids, overpayment recovery, provider/member issues.
Drive Agile ceremonies with the Product Owner - backlog grooming, prioritization, sprint planning, reviews.
Prepare audit deliverables for internal, OPM, and CMS reviews; mentor junior analysts and act as claims/FEP domain SME.

Required Qualifications
Bachelor's degree in IT, Computer Science, Health Informatics, Business, or related field.
8+ years as an IT/Business Systems Analyst in the healthcare payer domain.
5+ years hands-on with claims processing and adjudication systems.
3+ years direct FEP claims processing experience - FEP Direct/Express, FEP Blue plan structures, OPM/FEHB rules, FEP reporting cycles.
Hands-on experience with an enterprise claims platform: Facets, QNXT, HealthEdge HealthRules, NASCO, Amisys, or equivalent.
Working knowledge of HIPAA X12 5010 transactions: 837, 835, 834, 270/271, 276/277, 278.
Knowledge of ICD-10, CPT, HCPCS, DRG, revenue codes, modifiers, NDC, NPI, CMS-1500, UB-04.
Experience with COB/TPL, Medicare crossover, and subrogation rules.
Intermediate-to-advanced SQL for data analysis and validation.
Proven Agile/Scrum delivery experience with Jira, Azure DevOps, or Rally.
Strong process modeling skills (Visio, Lucid chart, BPMN) and audit-ready documentation discipline.
Solid HIPAA privacy/security and PHI handling knowledge.
Experience using AI-assisted tooling (Copilot, Devin, Windsurf) for requirements, test case generation, and spec-driven documentation.

Preferred Qualifications
BCBS plan experience, including Inter-Plan/ITS BlueCard host-home claims flows.
Claims platform implementation, conversion, or migration experience.
Provider contract configuration, fee schedules, and repricing logic.
Payment integrity tools (Optum CES, ClaimsXten) and EDI gateways (Edifecs, Availity, TriZetto).
Medicare Advantage, Medicaid, or ACA/Marketplace claims exposure.
Cloud/data platforms (AWS, Azure, Snowflake) and BI tools (Power BI, Tableau).
RPA for claims operations (UiPath, Automation Anywhere).
Certifications: CBAP, PMI-PBA, CSPO/SAFe POPM, AHIP, or AAPC/AHIMA coding credentials.

Technical Skills

Domain
Claims adjudication, pricing, payment, and remittance
FEP claims processing (FEP Direct/Express, OPM/FEHB rules)
Benefit administration, accumulators, COB/TPL, overpayment recovery
Regulatory: HIPAA, ACA, No Surprises Act, CMS mandates

Platforms
Facets / QNXT / HealthEdge HealthRules / NASCO / Amisys
FEP Direct / FEP Express
Optum CES / ClaimsXten

EDI & Integration
X12 5010 (837, 835, 834, 270/271, 276/277, 278), NCPDP
CMS-1500, UB-04, flat file, XML, JSON, REST APIs

Data & Reporting
SQL (Oracle, SQL Server, DB2, PostgreSQL)
Advanced Excel, data mapping and reconciliation
Power BI / Tableau; Snowflake (preferred)

Tools & Methods
Jira, Azure DevOps, Confluence, Visio, Lucid chart
qTest / Zephyr / ALM for test and defect management
Agile, Scrum, SAFe; AI-assisted spec-driven analysis

Additional Information:

Ability to work independently with minimal support
Follow Best practices while coding.
Ability to work with diverse group of stakeholders and integration teams to complete the work