We are looking for a Claims Business Analyst with 5+ years of experience in healthcare claims operations, business analysis, and process transformation. The ideal candidate will have strong knowledge of payer/provider claims processes and experience identifying opportunities for process optimization, automation, and digital transformation.
Key Responsibilities:
- Partner with healthcare operations and IT stakeholders to assess current-state claims processes and define transformation roadmaps.
- Analyze end-to-end claims lifecycle, including eligibility verification, claims submission, adjudication, remittance, payment posting, denials, and appeals.
- Work with EDI 837/835 workflows and identify process gaps, manual interventions, rework, and delays.
- Analyze root causes of claim denials, inaccuracies, and operational inefficiencies.
- Identify opportunities for process standardization, optimization, RPA, and AI/ML-based automation.
- Leverage process intelligence and task/process mining tools such as UiPath, Celonis, or equivalent.
- Define and track business KPIs such as cycle time, accuracy, denial rate, productivity, and operational efficiency.
- Develop business cases, ROI models, and high-level process/solution concepts for automation initiatives.
- Partner with architects, developers, and RPA teams to translate business requirements into effective technology solutions.
- Support automation initiatives through discovery, process design, UAT, and hypercare from a functional perspective.
- Conduct workshops with claims operations, billing/coding, payer relations, and other business stakeholders.
- Present analysis, recommendations, and transformation strategies to senior stakeholders.
- Support change management, communication, and transition activities.
Required Skills:
- 5+ years of experience in healthcare claims, healthcare operations, business analysis, or business consulting.
- Strong understanding of healthcare claims processes and end-to-end claims lifecycle.
- Experience in claims process analysis, optimization, and transformation.
- Hands-on knowledge of claims adjudication, denials, appeals, prior authorization, and/or revenue cycle processes.
- Understanding of EDI 837/835 workflows.
- Strong stakeholder management, workshop facilitation, problem-solving, and analytical skills.
- Ability to translate business problems into process improvement and technology-enabled solutions.
- Experience working with both business and IT stakeholders.
Good to Have:
- Experience with RPA, AI/ML, or intelligent automation initiatives.
- Experience with UiPath, Celonis, or equivalent process/task mining platforms.
- Experience developing automation business cases and ROI models.
- Experience with healthcare payer/provider environments.
- Knowledge of process mining, operational dashboards, and KPI frameworks.
- Experience supporting UAT, hypercare, and change management.