Senior Healthcare EDI Business Analyst – Payer Systems supports claims, membership, provider

Infinite Computer Solutions is a global leader in digital engineering and IT services, focusing on delivering innovative technology solutions. The Senior Healthcare EDI Business Analyst – Payer Systems role involves supporting claims, membership, provider, billing, and utilization management operations by analyzing business needs and translating them into system and process requirements, while collaborating with cross-functional teams nationwide.

Responsibilities:

• Analyze end‑to‑end payer workflows including eligibility, enrollment, provider setup, claims adjudication, premium billing, and authorization processes
• Identify gaps and recommend solutions to improve accuracy, reduce rework, and optimize turnaround times
• Document business rules, BRDs, FRDs, process maps, and user stories for payer-focused initiatives
• Partner with claims teams to understand payer rules, benefit structures, accumulators, and pricing logic
• Support configuration of provider contracts, authorization rules, benefits, and fee schedules
• Perform root-cause analysis of adjudication issues related to configuration, coding, or eligibility
• Assist with implementation, upgrades, and integrations of payer systems (Facets, QNXT, Amisys, HealthEdge, Tapestry)
• Ensure system workflows align with CMS and state regulatory requirements
• Conduct UAT, develop test scripts, validate outputs, and coordinate defect resolution
• Maintain compliance with CMS, NCQA, HIPAA, and state insurance guidelines
• Support regulatory submissions including Risk Adjustment, HEDIS, and Encounter Data Reporting
• Prepare documentation for audits and regulatory reviews
• Analyze membership, claims, provider, and utilization data to support operational and strategic decisions
• Build reports or dashboards using SQL, Excel, Power BI, or Tableau
• Provide data-driven insights to reduce cost of care and improve operational performance
• Serve as a liaison between Claims, UM, Enrollment, Provider Relations, Finance, and IT teams
• Facilitate requirements-gathering workshops and JAD sessions
• Provide training, SOPs, and ongoing support to remote and onshore/offshore teams

Requirements:

• Bachelor's degree in Healthcare, Business, Information Systems, or related field
• 2+ years of experience in a payer, managed care, or insurance environment
• Strong understanding of claims adjudication, benefits, eligibility, provider data, and CMS rules
• Experience with a payer platform: Facets, QNXT, Amisys, HealthEdge, Tapestry, etc
• Proficiency in requirements documentation, process mapping, and UAT
• Analytical ability with tools like SQL, Excel, Power BI