Full Job Description
Job Summary
We are seeking an experienced Healthcare Claims Business Analyst to drive requirements gathering, documentation and delivery for claims processing initiatives on Pega and Facets. Owns end-to-end claims lifecycle analysis - intake, adjudication, adjustments, provider reimbursement and payment processing - and translates business needs into functional specs, user stories, process flows and acceptance criteria.
Required Skills:
1. Healthcare Claims Processing
2. Pega
3. Facets (Claims, Membership, Billing, Provider)
4. EDI 837/835
5. Business Analysis
Job Description:
• Gather, analyze, and document business and system requirements for healthcare claims processing initiatives.
• Work closely with business stakeholders, product owners, developers, and QA teams to ensure requirements are accurately defined and implemented.
• Analyze healthcare claims workflows including claims intake, adjudication, adjustments, provider reimbursement, and payment processing.
• Work with Facets modules including Claims, Membership, Billing, and Provider to support end-to-end claims lifecycle management.
• Translate business requirements into functional specifications, user stories, process flows, and acceptance criteria.
• Analyze member, provider, claims, benefits, and authorization data to support operational and system enhancement initiatives.
• Support Agile development activities including backlog grooming, sprint planning, testing, defect triage, and release activities.
• Participate in requirements workshops, stakeholder discussions, and solution design reviews.
• Support User Acceptance Testing (UAT), validate business requirements, and assist with production issue analysis.
• Ensure healthcare claims requirements and workflows align with HIPAA and EDI 837/835 transaction standards.
