Lead- Business analyst

• Work Model: Work from Office
• Candidate Expectation
• Total Experience and Relevant: Overall 7-10 years of experience
• Candidate Location- India
• Skills- Business analyst, claims adjudication, ICD-10, CPT, HCPCS, Medicare, and Medicaid
• Education and CertificationQualification: Any graduates

Detailed Job DescriptionJD:

• 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
• KEY SKILLS: Experience in healthcare claims solutioning, business requirements analysis, and process transformation, with the ability to design client-centric claims solutions and translate business needs into functional specifications.
• Skilled in driving claims process improvement, automation, UAT, and stakeholder collaboration to enhance adjudication accuracy, turnaround time, and operational efficiency.