Claims Business Analyst
Department:

Claims
Effective Date:

October 12, 2023

Reports to:

Claims Director
Direct Reports:

None
FLSA:

Non-Exempt

Working Conditions: Remote, occasional travel to office, Normal, no adverse or hazardous conditions.

Primary Purpose:

Perform business analyst duties such as: evaluating existing process for process improvement and/or

department stabilization activities, frequent desk side walk-thru, process documentation, time studies,

best practice recommendations, creative remediation of existing processes and tools, intake for change

requests and project implementation - including new and existing business reasons, utilize key

performance indicator dashboards to determine priorities amongst a multiple priority and fast paced

environment.

Principal Duties and Responsibilities:
1. Document business processes end to end
2. Produce business plans of action for new projects and initiatives
3. Create reports for decision making purposes
4. Lead training sessions with staff
5. Facilitate meetings between internal and external stakeholders
6. Evaluate contracts and regulations to document business requirements
7. Recommend configuration for process automation purposes, core claims database and robotic
8. Data testing and universe specification document creation
9. Track change requests, projects, inbound health plan requests
10. Takes initiative and is creative and innovative in solving or recommending ways to solve

problems and issues

11. Maintains confidentiality in all endeavors
12. Will assist with other projects and duties as assigned.

Job Specifications (KSAs):

Five or more years practical work experience in a claims and service environment.

General understanding of CPT, ICD, CMS 1450 and 1500, EDI files, Maximum out of Pocket and

Member Benefits, Provider Disputes, Encounter Data, Vendor and Provider Relationship

Must have at least 5 to 10 years of medical claim data analysis experience.

Ability to generate regular daily, weekly, monthly updates on project status.

Advanced in MS Excel, must be able to create and use VLOOKUP, and Pivot Tables. General

understanding of SQL Query and Tables. Visio and process mapping.

Experience with requirement gathering of State, Federal, and Health Plan regulations.

Plans, directs, and implements procedures that will assure accurate and timely payment of claims.

Must have strong management, organization, communication, and decision-making skills

Position Performance Criteria:

1. Superior organizational and problem solving skills; excellent leadership and management skills.

2. Customer focused attitude.