Healthcare Claims Business Analyst / SME

InfoMC, Inc. is a fast-paced healthcare technology company specializing in integrated care management and population health solutions. The Healthcare Claims Business Analyst / SME will serve as the primary domain authority for healthcare claims operations, guiding clients through the onboarding process while ensuring compliance with payer-side business requirements and industry standards.

Responsibilities:

• Serve as the internal and client-facing subject matter expert on healthcare claims operations, EDI transaction standards, and payer-side adjudication logic throughout the Incedo onboarding lifecycle
• Translate client payer workflows and claims processing requirements into detailed business and functional specifications for the Incedo implementation team
• Advise clients on best practices for configuring claims intake, adjudication rules, coordination of benefits (COB), appeals and grievance workflows, and remittance processing within Incedo
• Identify gaps between client legacy processes and Incedo capabilities; document and escalate to product/engineering as applicable
• Support clients in designing claims data migration strategies, including crosswalks from legacy systems and validation of historical claims data integrity
• Lead business analysis workstreams during new client onboarding, including requirements discovery sessions, workflow mapping, and gap analysis documentation
• Develop and maintain detailed business requirements documents (BRDs), functional specifications, data mapping templates, and EDI companion guides customized to each client’s trading partner environment
• Coordinate with the client’s EDI team and clearinghouse partners to complete end-to-end transaction testing for all applicable X12 transaction sets
• Facilitate and support user acceptance testing (UAT) for claims processing scenarios, ensuring adjudication outcomes align with client benefit plan configuration and state/federal requirements
• Document client-specific configurations, workflow decisions, and known edge cases in InfoMC’s implementation knowledge base
• Partner with Engagement Managers and Technical Leads to ensure claims-related milestones are on track, risks are escalated promptly, and client expectations are managed
• Maintain current knowledge of CMS regulations, HIPAA transaction and code set standards (45 CFR Part 162), and state Medicaid agency requirements as they affect claims operations
• Advise clients on compliance with CMS-0057-F (electronic prior authorization), No Surprises Act (NSA) claims adjudication timelines, and applicable state prompt pay laws
• Support clients in Medicare Advantage (Part C), Medicaid managed care, and CHIP programs in configuring Incedo to meet CMS encounter data submission requirements
• Monitor and communicate updates to X12 transaction standards, ICD/CPT/HCPCS code set releases, and CMS NCCI edits that may affect client configurations
• Develop and maintain internal training materials, job aids, and onboarding playbooks related to claims operations and EDI workflows on the Incedo platform
• Mentor junior implementation staff on payer claims concepts, EDI troubleshooting, and client-facing discovery techniques
• Collaborate with InfoMC’s Product and Engineering teams to communicate client-driven enhancement requests and emerging market requirements
• Contribute to the ongoing refinement of InfoMC’s Implementation Playbook with claims-specific best practices and lessons learned

Requirements:

• Bachelor's Degree in Health Information Management, Healthcare Administration, Computer Science, Business, or equivalent work experience
• Minimum of 5 years of experience in a healthcare payer environment (health plan, managed care organization, TPA, or Medicare Advantage plan) in a claims operations or claims business analyst capacity
• Demonstrated hands-on experience with HIPAA X12 EDI transactions including 834, 837P/I/D, 835, 270/271, 275, 276/277, and 278
• Experience with claims adjudication systems, clearinghouse relationships, and payer-side EDI trading partner onboarding
• Familiarity with ICD-10, CPT, HCPCS Level II, revenue codes, and NCCI edits in the context of claims processing
• Experience supporting software implementations or system migrations in a healthcare payer context
• Ability to travel to client sites as needed (estimated up to 20%)
• This role is not eligible for sponsorship
• Experience with Medicare Advantage (Part C) or Medicaid managed care claims operations, including CMS encounter data submission
• Knowledge of CMS-0057-F electronic prior authorization requirements and their claims workflow implications
• Familiarity with No Surprises Act (NSA) independent dispute resolution and good faith estimate requirements
• Experience with utilization management or care management platforms that interface with claims adjudication
• CPHQ, RHIT, RHIA, or equivalent healthcare informatics certification
• Project Management Professional (PMP) certification
• SQL proficiency for claims data validation and ad hoc reporting
• Prior experience in a healthcare IT vendor or SaaS implementation environment