Senior IT Business Analyst-Claims

The Opportunity

We are seeking a Senior IT Business Analyst with deep healthcare claims experience to bridge Claims Operations and Information Technology. This IT-based role works closely with claims leaders, developers, data teams, project managers, vendors, and other business stakeholders.

The analyst will translate claims needs into clear, testable requirements; analyze claims processes and data; support solution design, testing, and implementation; and help investigate production issues. The role requires strong knowledge of claims administration, adjudication, benefits, pricing, payments, adjustments, and related data flows.

What You'll Do

Claims Subject Matter Expertise

- Serve as an IT-based subject matter expert for healthcare claims processes, systems, data, and projects.

- Analyze the end-to-end claims lifecycle, including intake, validation, adjudication, benefits, pricing, payment, adjustments, denials, and reporting.

- Partner with Claims Operations to document business rules, exceptions, pain points, and control requirements.

- Distinguish operational, configuration, data, vendor, and application issues.

- Assess how proposed changes may affect claim accuracy, financial controls, member and provider experience, and downstream systems.

Business and Systems Analysis

- Gather, document, validate, and prioritize business, functional, data, integration, and reporting requirements.

- Translate claims needs into user stories, process flows, business rules, data requirements, and acceptance criteria.

- Analyze claims workflows and data exchanges to identify gaps, risks, dependencies, and improvement opportunities.

- Facilitate requirements sessions and help stakeholders align on scope, ownership, priorities, and outcomes.

- Maintain traceability from requirements through design, development, testing, and implementation.

Solution and Data Analysis

- Work with architects, developers, data teams, and vendors to evaluate options and confirm that designs meet business requirements.

- Use SQL, reports, and system data to investigate claims issues, validate requirements, and support decisions.

- Define data mappings, validation rules, reconciliation requirements, exception handling, and monitoring needs.

- Review APIs, EDI transactions, file layouts, and data workflows related to claims processing.

- Identify impacts across eligibility, benefits, provider, network, pricing, payment, finance, reporting, and member-facing systems.

Testing and Implementation

- Develop test scenarios and acceptance criteria based on claims rules and expected outcomes.

- Coordinate system, integration, regression, and user acceptance testing with Claims Operations, Quality Assurance, developers, and vendors.

- Validate claim outcomes, financial results, data movement, reporting, and exception handling.

- Support implementation readiness, change management, training, and post-production validation.

- Confirm that solutions have documented ownership, monitoring, reconciliation, support procedures, and escalation paths.

Production Support and Root-Cause Analysis

- Analyze claims production issues, data discrepancies, processing failures, and unexpected adjudication outcomes.

- Gather evidence, reproduce issues, analyze data, and coordinate root-cause investigation across internal teams and vendors.

- Document business impact, interim mitigation, root cause, and permanent corrective action.

- Prioritize issues based on member and provider impact, financial exposure, compliance risk, and operational disruption.

Project Delivery and Continuous Improvement

- Lead the analysis workstream for claims-related technology projects and enhancements.

- Support scope definition, dependency management, status reporting, risk identification, and stakeholder communication.

- Maintain clear requirements, decisions, assumptions, open questions, and action items.

- Identify improvements to claims quality, automation, efficiency, monitoring, reporting, and customer experience.