Business Analyst - Prior Authorizations (Medicaid Claims Systems)Job Overview An immediate opportunity is available for an experienced Business Analyst with specialized knowledge of prior authorizations and healthcare claims processing. This role supports the enhancement, testing, and implementation of a Medicaid Management Information System (MMIS), with a focus on accurate reimbursement operations and member services. Candidates with hands-on Medicaid systems experience, strong analytical capabilities, and a solid understanding of prior authorization workflows will be best positioned for an interview.
Must Haves - Healthcare Business Analysis: At least three years of relevant professional experience, supported by a bachelor's degree or higher in business, information technology, healthcare administration, or equivalent experience in a healthcare administration environment.
- Prior Authorization Expertise: Strong understanding of prior authorization processes, including authorization workflows, service approvals, and related claims system functionality.
- Claims Processing Knowledge: Demonstrated experience with healthcare claims, provider reimbursement, payment processing, and referrals within complex healthcare systems.
- Systems Development Lifecycle (SDLC): Ability to contribute throughout the project lifecycle, including requirements analysis, solution design, development support, testing, implementation, and post-release stabilization.
- Requirements and Documentation: Proven ability to gather, analyze, validate, and document business and system requirements, translating operational needs into actionable specifications.
- Testing and Quality Assurance: Experience preparing test strategies, scenarios, and cases from documented requirements, executing test activities, reviewing results, and confirming functional readiness.
- Data Analysis and SQL: Strong analytical skills, including proficiency in SQL for data queries, investigation, validation, and reporting.
- Communication and Collaboration: Excellent written, verbal, and interpersonal skills, with the ability to work independently and coordinate effectively with technical teams, business users, vendors, and other stakeholders.
What the Client Needs You to Do The organization needs a detail-oriented Business Analyst to help ensure that Medicaid claims and prior authorization system enhancements meet business requirements, support program operations, and comply with applicable state and federal regulations. You will connect business stakeholders with technical delivery teams, identify functional gaps, validate system behavior, and support successful releases. Your contributions will help maintain reliable claims processing, improve operational effectiveness, and ensure that system changes deliver the intended outcomes for members and providers.
Key Responsibilities - Facilitate Requirements Workshops: Lead or participate in joint application design sessions with business stakeholders to identify needs, clarify workflows, and establish functional expectations.
- Analyze Business Processes: Assess existing claims processing, provider reimbursement, prior authorization, and referral functions to identify gaps, dependencies, and opportunities for improvement.
- Document Functional Requirements: Develop and maintain business requirements, functional specifications, process documentation, and supporting materials throughout the project lifecycle.
- Support System Design and Development: Collaborate with developers, systems analysts, project managers, and vendors to ensure proposed solutions align with business objectives and integrate effectively with the broader MMIS environment.
- Develop Testing Approaches: Create test strategies, scenarios, and detailed test cases based on approved requirements, with particular attention to claims, authorization, and payment processing.
- Execute and Validate Testing: Perform or coordinate testing activities, evaluate results, document defects, support issue resolution, and provide sign-off for assigned functional components when appropriate.
- Coordinate Implementation Activities: Participate in deployment planning, release execution, and post-implementation stabilization to help ensure system changes perform as intended.
- Monitor Post-Release Performance: Assist with identifying system issues, developing remediation approaches, tracking corrective actions, and confirming that fixes address the underlying problems.
- Maintain Stakeholder Communication: Share project updates, communicate functional changes, answer system-related questions, and represent the business analysis team in relevant meetings.
- Analyze Data and Support Team Operations: Use data queries and analytical techniques to investigate issues, validate system information, support program staff and external partners, and provide backup assistance to fellow analysts as needed.
Additional Information - Position Type: Business Analyst, healthcare information systems
- Work Location: Quincy, Massachusetts
- Work Arrangement: Hybrid, combining on-site attendance with remote work according to operational requirements.
- Standard Schedule: Monday through Friday, 9:00 a.m. to 5:00 p.m.
- Schedule Flexibility: Working arrangements and reporting expectations may change based on business needs.
- Technical Environment: Medicaid Management Information Systems, healthcare claims and payment transactions, prior authorization workflows, SQL-based data analysis, and system testing.
- Preferred Experience: Previous work with Medicaid programs, healthcare payer systems, or complex claims administration platforms is highly desirable. Familiarity with HIPAA transaction processing, X12 standards, interoperability, and Agile delivery practices is an advantage.
- Professional Expectations: The successful candidate will demonstrate sound judgment, analytical thinking, attention to detail, independent problem-solving, and the ability to collaborate across business and technical teams.
Candidates who combine prior authorization expertise with healthcare claims knowledge, structured business analysis, and practical testing experience are encouraged to apply.
W2 employees of Overture Partners who work 30 or more hours per week are eligible for the following benefits: medical (choice of 3 plans), 401(k) starting on day one, a variety of voluntary benefits including life and disability insurance, and sick time if required by law in the worked-in state/locality.
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