We are seeking an experienced Healthcare Business Systems Analyst (BSA) with strong knowledge of healthcare claims processing and pre-adjudication workflows. The ideal candidate will have hands-on experience analyzing healthcare EDI transactions, claim intake and validation processes, and the flow of claims from trading partners through pre-adjudication and into the core claims adjudication system.
Key Responsibilities
- Analyze and document end-to-end healthcare claim workflows, with a strong focus on pre-adjudication processing.
- Work extensively with 837 Professional (837P) and Institutional (837I) claim transactions.
- Understand the claim lifecycle from provider/trading partner clearinghouse/gateway EDI/pre-adjudication platform core adjudication system.
- Analyze pre-adjudication processes including:
- File and transaction validation
- HIPAA/X12 compliance validation
- Trading partner and submitter validation
- Member and provider validation
- Duplicate and business-rule validations
- Claim balancing and control totals
- Claim acceptance/rejection
- Error handling and exception processing
- Strong understanding of 999 Functional Acknowledgment and 277CA Claim Acknowledgment transactions and their relationship to 837 processing.
- Analyze rejected claims and identify whether issues originate from the trading partner, EDI/pre-adjudication layer, mapping/transformation logic, or downstream claims system.
- Gather and translate business requirements into business requirements, functional requirements, user stories, process flows, mapping documents, and acceptance criteria.
- Conduct requirements-gathering sessions with business, EDI, claims operations, development, testing, and vendor teams.
- Perform gap analysis and impact analysis for new implementations and changes to existing claim-processing workflows.
- Support SIT/UAT by developing test scenarios, reviewing test results, validating claim outcomes, and assisting with defect analysis.
- Work closely with technical teams to troubleshoot production issues involving claim intake, validation, rejection, and downstream processing.
Required Qualifications
- 5+ years of Business Systems Analyst experience, preferably within healthcare payer environments.
- Strong hands-on knowledge of healthcare claims and pre-adjudication processes.
- Strong understanding of HIPAA X12 EDI transactions, particularly:
- 837P
- 837I
- 999
- 277CA
- Good understanding of Professional and Institutional claims and associated claim and service-line data.
- Experience working with Medicaid and/or Medicare managed care environments preferred.
- Understanding of the distinction between pre-adjudication edits/rejections and claims adjudication edits/denials.
- Experience documenting as-is/to-be workflows, business rules, functional requirements, user stories, and acceptance criteria.
- Strong analytical and troubleshooting skills, including the ability to trace claims across multiple systems.
- Experience with SQL/data analysis for claim research and validation is highly preferred.
- Experience working in Agile/Scrum environments and Jira is preferred.
Preferred Experience
Experience with healthcare payer core administration and EDI platforms such as Facets or similar claims systems, EDI gateways/translators, clearinghouses, and claim intake/pre-adjudication applications is highly desirable.
Primary Skill: Healthcare BSA – Claims Pre-Adjudication
Secondary Skills
837P/837I, 999, 277CA, HIPAA X12, Claims Processing, Requirements Analysis, SQL, Jira
Industry: Healthcare Payer / Medicaid / Medicare