The Opportunity

We are seeking a Senior IT Business Analyst with deep healthcare claims experience to bridge Claims Operations and Information Technology. This IT-based role works closely with claims leaders, developers, data teams, project managers, vendors, and other business stakeholders.

The analyst will translate claims needs into clear, testable requirements; analyze claims processes and data; support solution design, testing, and implementation; and help investigate production issues. The role requires strong knowledge of claims administration, adjudication, benefits, pricing, payments, adjustments, and related data flows.

What You'll Do

Claims Subject Matter Expertise

• Serve as an IT-based subject matter expert for healthcare claims processes, systems, data, and projects.
• Analyze the end-to-end claims lifecycle, including intake, validation, adjudication, benefits, pricing, payment, adjustments, denials, and reporting.
• Partner with Claims Operations to document business rules, exceptions, pain points, and control requirements.
• Distinguish operational, configuration, data, vendor, and application issues.
• Assess how proposed changes may affect claim accuracy, financial controls, member and provider experience, and downstream systems.

Business and Systems Analysis

• Gather, document, validate, and prioritize business, functional, data, integration, and reporting requirements.
• Translate claims needs into user stories, process flows, business rules, data requirements, and acceptance criteria.
• Analyze claims workflows and data exchanges to identify gaps, risks, dependencies, and improvement opportunities.
• Facilitate requirements sessions and help stakeholders align on scope, ownership, priorities, and outcomes.
• Maintain traceability from requirements through design, development, testing, and implementation.

Solution and Data Analysis

• Work with architects, developers, data teams, and vendors to evaluate options and confirm that designs meet business requirements.
• Use SQL, reports, and system data to investigate claims issues, validate requirements, and support decisions.
• Define data mappings, validation rules, reconciliation requirements, exception handling, and monitoring needs.
• Review APIs, EDI transactions, file layouts, and data workflows related to claims processing.
• Identify impacts across eligibility, benefits, provider, network, pricing, payment, finance, reporting, and member-facing systems.

Testing and Implementation

• Develop test scenarios and acceptance criteria based on claims rules and expected outcomes.
• Coordinate system, integration, regression, and user acceptance testing with Claims Operations, Quality Assurance, developers, and vendors.
• Validate claim outcomes, financial results, data movement, reporting, and exception handling.
• Support implementation readiness, change management, training, and post-production validation.
• Confirm that solutions have documented ownership, monitoring, reconciliation, support procedures, and escalation paths.

Production Support and Root-Cause Analysis

• Analyze claims production issues, data discrepancies, processing failures, and unexpected adjudication outcomes.
• Gather evidence, reproduce issues, analyze data, and coordinate root-cause investigation across internal teams and vendors.
• Document business impact, interim mitigation, root cause, and permanent corrective action.
• Prioritize issues based on member and provider impact, financial exposure, compliance risk, and operational disruption.

Project Delivery and Continuous Improvement

• Lead the analysis workstream for claims-related technology projects and enhancements.
• Support scope definition, dependency management, status reporting, risk identification, and stakeholder communication.
• Maintain clear requirements, decisions, assumptions, open questions, and action items.
• Identify improvements to claims quality, automation, efficiency, monitoring, reporting, and customer experience.

What We Expect From You

Required Qualifications

• Bachelor's degree in information systems, business, healthcare administration, or a related field, or equivalent experience.
• Five or more years of experience in healthcare claims operations, claims systems analysis, business analysis, or a related role.
• Strong knowledge of healthcare claims processing and adjudication.
• Ability to translate complex claims processes and rules into clear, testable technology requirements.
• Experience analyzing claims data, researching processing issues, and validating system outcomes.
• Experience facilitating requirements sessions across business, technical, and vendor teams.
• Working knowledge of SQL and relational data concepts sufficient to investigate issues and validate data.
• Strong analytical, documentation, problem-solving, and communication skills.

Preferred Qualifications

• Experience with a third-party administrator, health plan, claims administrator, healthcare network, or claims technology vendor.
• Familiarity with VBA Claims Software.
• Experience with medical claims, eligibility, benefits, provider data, network pricing, accumulators, explanations of benefits, adjustments, and payments.
• Familiarity with X12 claims, claim status, remittance, eligibility, and related healthcare transactions.
• Experience with claims platform configuration, vendor integrations, reporting, or data reconciliation.
• Familiarity with Microsoft Azure, Azure DevOps, Power BI, SQL Server, APIs, or ETL processes.
• Understanding of HIPAA, healthcare data privacy, security controls, auditability, and protected health information.

How Success Will Be Measured

• Requirements are complete, testable, and understood by business and technical teams.
• Claims-related changes produce accurate adjudication, pricing, payment, and reporting outcomes.
• Production issues are resolved through efficient investigation and documented corrective actions.
• Projects identify dependencies, data impacts, readiness needs, and vendor responsibilities before implementation.
• Improvements reduce manual work, recurring defects, avoidable claim adjustments, or operational risk.

Role Ownership and Collaboration

We make healthcare EZ!

Additional Opportunity Details:

Target Base Compensation Range for this role is $90,000-$120,000*

*Factors that may be used to determine your actual salary include your job specific skills, education, training, job location, number of years of experience related to this role and comparison to other employees already in this role. *

Employee benefits are part of the competitive total rewards package that HealthEZ provides to you. Our comprehensive benefits program includes health benefits, retirement plan (401k), paid time off, paid leave including parental leave and more.

HealthEZ recognizes its responsibilities under federal, state and local laws requiring non-discriminatory employment practices. All employment decisions, practices and procedures will be carried out without regard to race, color, creed, religion and sex (including pregnancy), sexual orientation, national origin or ancestry, age, marital status, disability, family status, status with regard to public assistance or any other characteristic protected under applicable local, state and federal laws.

HealthEZ is proud to be an equal opportunity employer.

Salary : $90,000 - $130,000