BA - US Healthcare

JOB Description: Claims BA

The Business Analyst (Claims Adjudication) responsible for analyzing, documenting, and optimizing claims adjudication processes to ensure accurate, timely, and compliant claim payments, acts as a bridge between business stakeholders, claims operations teams, clients, and technology teams to drive system enhancements, process improvements, and regulatory compliance.

Key Responsibilities

•          Analyse end-to-end claims adjudication workflows, including claim intake, validation, pricing, edits, benefits application, payment, and denial processes.

•          Gather and document business requirements for claims processing system enhancements.

•          Translate business needs into functional specifications, user stories, and process flows.

•          Evaluate claim processing rules, benefit plans, fee schedules, provider contracts, and reimbursement methodologies.

•          Support implementation of new claim edits, policies, and regulatory changes.

•          Identify operational gaps and recommend automation opportunities.

•          Perform root cause analysis for claim payment issues, pended claims, and adjudication defects.

•          Analyze denial trends, provider disputes, and payment accuracy metrics.

•          Improve turnaround time (TAT), first-pass auto-adjudication rates, and operational efficiency.

•          Collaborate with Claims Operations, Configuration, Provider Network, Compliance, and IT teams.

•          Facilitate requirement workshops and stakeholder meetings.

•          Provide business support during project implementation and production deployments.

•          Develop test scenarios and test cases.

•          Execute and support User Acceptance Testing (UAT).

•          Validate claims adjudication outcomes against business requirements.

•          Track defects and coordinate resolution with development teams

•           

Domain and Business analysis Skills

•          Healthcare, Dental, Medicare, Medicaid, or Commercial Claims Processing.

•          Claims lifecycle management.

•          Claims adjudication rules and payment methodologies.

•          Provider contracts and fee schedules.

•          Benefits, eligibility, COB, and authorization processes.

•          Medical coding (ICD-10, CPT, HCPCS) and/or Dental Coding (CDT Codes)

•          Requirement Gathering

•          Process Mapping

•          Gap Analysis /  Root Cause Analysis

•          UAT Planning and Execution

•          Preferred knowledge different claims processing platforms

Qualification

•          Bachelor's Degree in Business, Healthcare Administration, Information Systems, or related field.

•          7-10 years of experience in healthcare or Medical / dental claims processing/business analysis.

•          Strong understanding of claims adjudication systems and payer operations. Preferred with BA Role Experience