Role: Senior Business Analyst with Claims module
Location: Remote
Primary skills: Strong experience/ knowledge of Claims Process- How claims are processed and how pricing is done in Medicaid Field.
Senior Business Analyst – Claims module:
Play the role of Claims Domain lead for MMIS health care projects. Drive the claims module and process, domain knowledge, perform analysis of business requirements, design and develop documentation, ensure quality process, coordinates with customers. Works in team environment and provides guidance throughout the entire life cycle. Responsible for meeting customer expectations, troubleshooting problems in the application and assisting customers in implementation decisions.
1. Candidate should have strong health care domain experience and should have good knowledge of Medicaid and Medicare.
2. Candidate should have hands-on experience in claims processing and Adjudication processes.
3. Must have good experience in Reference code/data sets required in Claims adjudication.
4. Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
5. Should be able to run queries and perform basic system analysis, RCA etc.,
6. Should work closely with the client and development team during the stages of development, and conduct demos at completion of milestone, track and close feedback from such demos
7. Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks
8. Work Closely with Dev, architecture, and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
9. In depth understanding of Claims and Claims lifecycle:
- Member
- Provider
- Claim submission – Paper and EDI X12
- Adjudication
- Payment Cycle (Finance)
- Reporting
10. Claim Types:
- Professional
- Dental
- Institutional
- Pharmacy
- Encounters and Capitation
11. Claim Formats:
- EDI X12 formats like 837P/I/D
- X12 formats 835, 834, 270/271, 276/277
12. Claim System:
- Familiarity with systems like CMdS, GHS, Facets and etc
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