Job Summary
The Senior Healthcare Business Analyst / Behavioral Health SME will provide subject matter expertise across Healthcare Payer operations with a focus on Behavioral Health, including Mental Health and Substance Use Disorders. The role requires strong understanding of the end-to-end payer lifecycle, Behavioral Health regulations, payer technology platforms, healthcare transactions, interoperability, business analysis, data analysis, and system integrations. The ideal candidate will combine deep Behavioral Health payer expertise with business analysis and system knowledge to drive strategic business discussions and detailed system-level solution design.
Key Responsibilities
• Gather and analyze business and system requirements across Healthcare Payer operations and Behavioral Health.
• Develop BRDs, FRDs, user stories, process maps, and gap analyses.
• Support UAT and SIT activities and coordinate with business and technology stakeholders.
• Analyze the end-to-end payer lifecycle, including eligibility and enrollment, benefits configuration, claims processing and adjudication, prior authorization, care and case management, provider management, appeals and grievances, and payment integrity.
• Apply knowledge of Behavioral Health regulations, including MHPAEA, Medicare and Medicaid Behavioral Health programs, HIPAA, CMS and state-specific requirements, and NCQA/URAC standards.
• Work with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare, or similar platforms.
• Analyze healthcare transactions and interoperability standards including 837, 835, 834, 270/271, HL7, and FHIR.
• Perform SQL-based analysis and support data analysis and system integration activities.
• Collaborate with business, technology, operations, and other stakeholders to define and implement solutions.
• Support payer modernization, data, AI, and digital transformation initiatives where applicable.
Required Qualifications
• 10+ years of Healthcare Payer experience.
• 5+ years of experience in Behavioral Health, including Mental Health and Substance Use Disorders.
• Strong understanding of the end-to-end payer lifecycle, including eligibility and enrollment, benefits configuration, claims processing and adjudication, prior authorization, care and case management, provider management, appeals and grievances, and payment integrity.
• Deep knowledge of Behavioral Health regulations, including MHPAEA, Medicare and Medicaid Behavioral Health programs, HIPAA, CMS and state-specific regulatory requirements, and NCQA/URAC standards.
• Strong Business Analysis skills, including requirements gathering, BRD/FRD development, user stories, process mapping, gap analysis, UAT/SIT support, and stakeholder management.
• Experience with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare, or similar.
• Knowledge of healthcare transactions and interoperability standards including 837, 835, 834, 270/271, HL7, and FHIR.
• Strong SQL and data analysis skills.
• Strong understanding of system integration concepts.
• Ability to drive both strategic business discussions and detailed system-level solution design discussions.
Preferred Qualifications
• Experience with Commercial, Medicare, and Medicaid lines of business.
• Exposure to Behavioral Health care management, utilization management, and value-based care programs.
• Experience working on payer modernization, data, AI, or digital transformation initiatives.
