[Hiring] Claims Module Senior Business Analyst @Conduent State Healthcare, LLC

Role Description

This individual will play the role of Claims Domain lead for MMIS health care projects.

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.

Qualifications

• 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 stakeholders 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.
• Communication: Collaborate with cross-functional teams.

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.
• Should work closely with the client and development team during the stages of development, and conduct demos at completion of milestones, track and close feedback from such demos.
• Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks.
• Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
• 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.

Benefits

• Career Growth Opportunities: We help you thrive, so together, we can grow. We provide opportunities to advance your career with a vast portfolio of businesses and a global footprint.
• Great Work Environment: We are proud of our award-winning culture and the recognition we’ve received for our diversity efforts.
• Remote work: Enjoy the convenience of working from home and maximize your time by unplugging at the end of your workday.