Claims Module Senior Business Analyst

Conduent delivers mission-critical services and solutions for clients and governments. The Claims Module Senior Business Analyst will lead the claims domain for MMIS health care projects, providing domain expertise and driving claims processes. The role involves analyzing business requirements, developing documentation, coordinating with customers and development teams, troubleshooting application issues, and supporting implementation decisions.

Responsibilities:

• Drive the claims module and process and provide domain knowledge
• Perform analysis of business requirements
• Design and develop documentation and ensure quality process while coordinating with customers
• Work in a team environment and provide guidance throughout the entire life cycle
• Responsible for meeting customer expectations and troubleshooting problems in the application
• Assist customers in implementation decisions

Requirements:

• Candidate should have strong health care domain experience and should have good knowledge of Medicaid and Medicare
• Candidate should have hands-on experience on claims processing and Adjudication processes
• Must have good experience in Reference code/data sets required in Claims adjudication
• Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems
• Should be able to run queries and perform basic system analysis, RCA etc
• Must have excellent written and spoken communication skills
• Should be able to multitask between internal team and clients based on priority tasks
• In depth understanding of Claims and Claims lifecycle:
• Member, Provider, Claim submission – Paper and EDI X12, Adjudication, Payment Cycle (Finance), Reporting
• Claim Types: Professional, Dental, Institutional, Pharmacy, Encounters and Capitation
• Claim Formats: EDI X12 formats like 837P/I/D, X12 formats 835, 834, 270/271, 276/277
• Claim System: Familiarity with systems like CMdS, GHS, Facets and etc
• SQL: To validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan)
• EDI Tools: Validating X12 files
• Interface Testing: Understanding how data flows between systems and formats and use tools like postman
• Minimum of 8+ years of experience in health care experience especially in MMIS domain
• Capability to think out-of-the-box to create new solutions as needed
• Ability to validate Test scenarios and test plans, test data
• Should be able to Review requirements, documentation and create Requirements Traceability matrix (RTM)
• Should have excellent communication (written and spoken) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units
• Ability to assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product
• Ability to drive and share the requirements with Technical and Architects regarding product features to be implemented