Role: Business Analyst Location: Remote Duration: 3 Months
What are the top 3 skills required for this role? • Strong expertise in Claims processing • Strong expertise in FEP line of business • Strong System Analyst, business analysis experience in healthcare industry. Healthcare payer domain.
Job Description/ Responsibilities: • BA bridging Claims Operations and IT delivery for a health plan, with deep expertise in claims adjudication and Federal Employee Program (FEP) claims processing. Owns requirements, data mapping, and validation across the claims lifecycle.
Key Responsibilities: • Elicit and document business/functional requirements for claims adjudication, pricing, and payment systems — BRDs, FRDs, user stories with acceptance criteria, business rules, and traceability matrices. • Analyze the end-to-end claims lifecycle (intake → EDI → edits → pend resolution → adjudication → pricing → COB → payment → remittance) and drive gap closure and automation. • Own FEP-specific requirements: FEP Direct/Express workflows, FEP Blue Standard/Basic/Focus benefit structures, annual brochure benefit changes, and FEP Operations Center files and reporting. • Translate OPM/FEHB guidance and carrier letters into system requirements and configuration change requests. • Perform source-to-target data mapping for X12 transactions (837, 835, 834, 270/271, 276/277, 278) and proprietary claim layouts. • Document and validate claims business rules: accumulators, benefit limits, authorization matching, timely filing, duplicate logic, contract pricing, and edit dispositions. • Write SQL to profile claims data, validate adjudication outcomes, and perform root-cause analysis on production defects. • Define test scenarios and lead SIT/regression/UAT cycles, defect triage, and business sign-off. • Lead requirements for mandate and regulatory releases (CMS updates, No Surprises Act, annual ICD-10/CPT/HCPCS code updates). • Support production escalations: payment discrepancies, adjustments/voids, overpayment recovery, provider/member issues. • Drive Agile ceremonies with the Product Owner — backlog grooming, prioritization, sprint planning, reviews. • Prepare audit deliverables for internal, OPM, and CMS reviews; mentor junior analysts and act as claims/FEP domain SME.
Required Qualifications • Bachelor's degree in IT, Computer Science, Health Informatics, Business, or related field. • 8+ years as an IT/Business Systems Analyst in the healthcare payer domain. • 5+ years hands-on with claims processing and adjudication systems. • 3+ years direct FEP claims processing experience — FEP Direct/Express, FEP Blue plan structures, OPM/FEHB rules, FEP reporting cycles. • Hands-on experience with an enterprise claims platform: Facets, QNXT, HealthEdge HealthRules, NASCO, Amisys, or equivalent. • Working knowledge of HIPAA X12 5010 transactions: 837, 835, 834, 270/271, 276/277, 278. • Knowledge of ICD-10, CPT, HCPCS, DRG, revenue codes, modifiers, NDC, NPI, CMS-1500, UB-04. • Experience with COB/TPL, Medicare crossover, and subrogation rules. • Intermediate-to-advanced SQL for data analysis and validation. • Proven Agile/Scrum delivery experience with Jira, Azure DevOps, or Rally. • Strong process modeling skills (Visio, Lucid chart, BPMN) and audit-ready documentation discipline. • Solid HIPAA privacy/security and PHI handling knowledge. • Experience using AI-assisted tooling (Copilot, Devin, Windsurf) for requirements, test case generation, and spec-driven documentation.
Preferred Qualifications • BCBS plan experience, including Inter-Plan/ITS BlueCard host-home claims flows. • Claims platform implementation, conversion, or migration experience. • Provider contract configuration, fee schedules, and repricing logic. • Payment integrity tools (Optum CES, ClaimsXten) and EDI gateways (Edifecs, Availity, TriZetto). • Medicare Advantage, Medicaid, or ACA/Marketplace claims exposure. • Cloud/data platforms (AWS, Azure, Snowflake) and BI tools (Power BI, Tableau). • RPA for claims operations (UiPath, Automation Anywhere). • Certifications: CBAP, PMI-PBA, CSPO/SAFe POPM, AHIP, or AAPC/AHIMA coding credentials.
Data & Reporting • SQL (Oracle, SQL Server, DB2, PostgreSQL) • Advanced Excel, data mapping and reconciliation • Power BI / Tableau; Snowflake (preferred)
Tools & Methods • Jira, Azure DevOps, Confluence, Visio, Lucid chart • qTest / Zephyr / ALM for test and defect management • Agile, Scrum, SAFe; AI-assisted spec-driven analysis
Additional Information:
• Ability to work independently with minimal support • Follow Best practices while coding. • Ability to work with diverse group of stakeholders and integration teams to complete the work.
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $47.00/hr - $50.00/hr.
