[Hiring] Senior Healthcare Business Analyst / Behavioral Health SME @Applabsystems

Role Description

We are seeking a seasoned Behavioral Health SME with strong Business Analysis and healthcare payer systems expertise to support payer transformation initiatives. The ideal candidate should have deep knowledge of Behavioral Health operations, end-to-end payer processes, healthcare regulations, and the ability to effectively bridge business and technology teams.

Qualifications

• 10+ years of Healthcare Payer experience, including 5+ years in Behavioral Health (Mental Health & Substance Use Disorders)
• Strong understanding of the end-to-end payer lifecycle, including:
  • Eligibility & Enrollment
  • Benefits Configuration
  • Claims Processing & Adjudication
  • Prior Authorization
  • Care & Case Management
  • Provider Management
  • Appeals & Grievances
  • Payment Integrity
• Strong knowledge of Behavioral Health regulations, including MHPAEA, Medicare/Medicaid, HIPAA, CMS, and state-specific requirements
• Familiarity with NCQA/URAC standards
• Strong Business Analysis experience with:
  • Requirements gathering
  • BRD/FRD
  • User stories
  • Process mapping
  • Gap analysis
  • UAT/SIT
  • Stakeholder management
• Experience with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare, or similar
• Knowledge of healthcare transactions and interoperability standards including 837, 835, 834, 270/271, HL7, and FHIR
• Strong SQL, data analysis, and system integration experience
• Experience with Commercial, Medicare, and Medicaid lines of business is preferred
• Exposure to Behavioral Health care management, utilization management, and value-based care programs is preferred
• Experience with payer modernization, data, AI, or digital transformation initiatives is a plus

Company Description