Role Overview Seeking a seasoned
Behavioral Health SME with strong Business Analyst and healthcare systems expertise to support payer transformation initiatives. The ideal candidate will have deep knowledge of Behavioral Health operations, end-to-end payer processes, and healthcare regulations, along with the ability to bridge business and technology teams.
Key Requirements - 10+ years of Healthcare Payer experience with 5+ years in Behavioral Health (Mental Health & Substance Use Disorders) .
- Strong understanding of the end-to-end payer lifecycle :
- Eligibility & Enrollment
- Benefits Configuration
- Claims Processing & Adjudication
- Prior Authorization
- Care & Case Management
- Provider Management
- Appeals & Grievances
- Payment Integrity
- Deep knowledge of Behavioral Health regulations , including:
- MHPAEA (Mental Health Parity)
- Medicare & Medicaid BH programs
- HIPAA
- CMS and State-specific regulatory requirements
- NCQA/URAC standards
- Strong Business Analysis skills:
- Requirements gathering
- BRD/FRD/User Stories
- Process mapping
- Gap analysis
- UAT/SIT support
- Stakeholder management
- Experience with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare, or similar .
- Knowledge of healthcare transactions and interoperability standards:
- 837, 835, 834, 270/271
- HL7/FHIR
- Strong SQL, data analysis, and system integration understanding.
Preferred - 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.
Ideal Candidate The ideal candidate will be a Behavioral Health payer SME who combines deep business process knowledge, regulatory expertise, system knowledge, and business analysis skills, with proven experience across:
Behavioral Health + Claims + Eligibility + Benefits + Care Management + Provider Operations + Regulatory Compliance + Payer Technology Platforms.
This person should be capable of driving both strategic business discussions and detailed system-level solution design discussions with equal effectiveness.
