Role: Business Analyst Mode: Remote Duration: 6 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.
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.
Years of Experience: 8.00 Years of Experience
Applicant Notices & Disclaimers
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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.The pay rate for this position is $50.00/hr.
