This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.

Role Description

In this role, you will lead high-impact business analysis initiatives focused on improving claims payment accuracy and operational efficiency across healthcare programs. You will collaborate with cross-functional teams to identify revenue opportunities, investigate root causes of payment discrepancies, and translate complex healthcare policies into actionable business rules. This position plays a key role in supporting payment integrity initiatives across Medicare, Medicaid, and commercial markets while guiding analytical teams and influencing strategic decision-making. You will work with large, multi-source healthcare datasets and partner with operational, actuarial, and technical stakeholders to deliver measurable financial and operational outcomes. Ideal candidates bring strong healthcare domain expertise, advanced analytical capabilities, and the ability to drive cross-functional collaboration in complex environments.

• Lead end-to-end business analysis efforts across claims adjudication, payment integrity reviews, audit recovery, appeals, and fraud, waste, and abuse (FWA) investigations.
• Identify revenue and cost-saving opportunities by analyzing duplicate claims, pricing errors, eligibility discrepancies, and other payment leakage sources.
• Act as the primary liaison between business sponsors, payment integrity SMEs, actuarial teams, provider operations, and technical delivery teams.
• Translate healthcare policies, benefit structures, contract terms, and payment guidelines into clear business rules and functional requirements.
• Develop and refine requirements, business rule logic, and acceptance criteria for payment integrity initiatives and system enhancements.
• Analyze data quality, perform financial impact assessments, and validate projections related to payment integrity programs.
• Mentor and guide Business Analysts, ensuring consistent analytical standards, documentation quality, and best practices.
• Conduct deep-dive investigations into claim-level patterns, provider anomalies, pricing discrepancies, and eligibility mismatches.
• Support leadership reporting, audit responses, regulatory documentation, and operational performance reviews.
• Participate in roadmap planning, initiative prioritization, and cross-functional strategy discussions.

Qualifications

• Bachelor’s degree in Business, Health Administration, Finance, or a related field.
• 8+ years of Business Analysis experience within the U.S. healthcare industry.
• Strong understanding of claims adjudication, payment policies, benefit design, and healthcare reimbursement models.
• Demonstrated leadership in cross-functional collaboration and stakeholder management.
• Experience interpreting healthcare guidelines and translating them into functional business requirements.
• Excellent analytical, problem-solving, and decision-making capabilities.
• Experience facilitating workshops, requirements sessions, and cross-functional planning meetings.
• Strong written and verbal communication skills with the ability to present insights to leadership.
• Ability to manage multiple priorities while maintaining attention to detail and analytical rigor.
• Familiarity with call center datasets for member/provider interactions and service navigation insights.
• Experience working with provider revenue cycle management (RCM) data, billing patterns, and clinical documentation alignment.
• Exposure to EHR or clinical datasets to validate medical necessity and care patterns.
• Knowledge of payment integrity reporting including duplicate claim detection, pricing anomalies, and eligibility mismatches.

Preferred Qualifications

• Experience in Claims Payment Integrity, FWA programs, provider contracting, billing, or revenue cycle operations.
• Deep knowledge of Medicare and Medicaid programs.
• SQL skills for data analysis, validation, and reporting.
• Familiarity with PBM systems, eligibility logic, or provider credentialing platforms.

Benefits

• Competitive contract compensation package.
• Fully remote work environment within the United States.
• Opportunity to lead high-impact initiatives improving healthcare payment accuracy and operational performance.
• Exposure to large-scale healthcare datasets and advanced analytical projects.
• Collaborative environment working with actuarial, operational, and technical stakeholders.
• Professional development opportunities within healthcare analytics and payment integrity programs.
• Flexible work structure supporting work-life balance.