Clinical Business Systems Analyst (Clinical BSA)

Vaiticka Solution is seeking a Senior Clinical Business Systems Analyst with extensive healthcare payer experience. This role focuses on supporting Medicaid/Medicare initiatives to improve care delivery and outcomes while acting as a clinical and functional subject matter expert.

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, focused on Population Health, Utilization Management (UM), and Care/Case Management (CM)
• Acts as a clinical + functional SME, supporting Medicaid/Medicare initiatives to improve care delivery, outcomes, and compliance
• 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, and acceptance criteria
• Support initiatives around risk stratification, care gap identification/closure, member outreach, outcomes and quality tracking
• 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
• Work with data/reporting teams to ensure clinical data accuracy
• Act as a bridge between clinical teams (nurses, care managers, medical directors) and 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
• 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