Senior Clinical Business Systems Analyst

Vaiticka Solution is seeking a Senior Clinical Business Systems Analyst with extensive healthcare payer experience. The role focuses on supporting Medicaid/Medicare initiatives and improving care delivery, outcomes, and compliance.

Responsibilities:

• Population Health, UM & Care Management
• Clinical SME for systems supporting Pop Health, UM, and CM
• Analyze and document end‑to‑end clinical workflows, including:
• Care plans
• Prior authorizations & utilization review
• Clinical assessments
• Care coordination & transitions of care
• Convert clinical and business needs into:
• Functional requirements
• User stories
• Acceptance criteria
• Support initiatives around:
• Risk stratification
• Care gap identification/closure
• Member outreach
• Outcomes and quality tracking
• Clinical Process & Requirements Analysis
• Perform gap analysis, impact analysis, and process modeling
• Create and maintain:
• BRDs / FRDs
• Workflow diagrams
• Data mappings & traceability matrices
• Partner with clinical ops, medical management, and compliance teams
• Ensure solutions align with evidence‑based care models and regulations
• Data Analysis & Reporting
• Use SQL to validate:
• Care management data
• Authorization decisions
• Clinical outcomes & quality measures
• Utilization metrics
• Work with data/reporting teams to ensure clinical data accuracy
• Stakeholder Collaboration
• Act as a bridge between:
• Clinical teams (nurses, care managers, medical directors)
• Business stakeholders
• IT, data, and integration teams
• Lead cross‑functional sessions
• Present complex concepts to non‑technical stakeholders
• Manage backlog and priorities in Agile/Scrum
• Testing, Quality & Compliance
• Define and support UAT
• Validate clinical workflows and authorization logic
• Support defect triage with QA teams
• Ensure compliance with:
• HIPAA
• CMS guidelines
• State Medicaid regulations
• Support audits and PHI/PII security reviews

Requirements:

• 10+ years of healthcare payer experience
• Experience focused on Population Health, Utilization Management (UM), and Care/Case Management (CM)
• Act as a clinical + functional SME
• Analyze and document end‑to‑end clinical workflows, including care plans, prior authorizations & utilization review, clinical assessments, care coordination & transitions of care
• Convert clinical and business needs into functional requirements, user stories, and acceptance criteria
• Perform gap analysis, impact analysis, and process modeling
• Create and maintain BRDs / FRDs, workflow diagrams, data mappings & traceability matrices
• Partner with clinical ops, medical management, and compliance teams
• Ensure solutions align with evidence‑based care models and regulations
• Use SQL to validate care management data, authorization decisions, clinical outcomes & quality measures, and utilization metrics
• Act as a bridge between clinical teams (nurses, care managers, medical directors), business stakeholders, and IT, data, and integration teams
• Lead cross‑functional sessions
• Present complex concepts to non‑technical stakeholders
• Manage backlog and priorities in Agile/Scrum
• Define and support UAT
• Validate clinical workflows and authorization logic
• Support defect triage with QA teams
• Ensure compliance with HIPAA, CMS guidelines, and State Medicaid regulations
• Support audits and PHI/PII security reviews