What are the responsibilities and job description for the Business Analyst - Prior Authorization & Claims Operations 5691 position at Tier4 Group?
Business Analyst - Prior Authorization & Claims Operations
LONG Term Contract - Potentially Multi- Year
Mostly Remote Opportunity - 1 Day Per Month in Quincy, MA Office
We are seeking an experienced Business Analyst with strong Prior Authorization (PA) expertise to support healthcare claims and reimbursement initiatives within a complex healthcare technology environment. This role will focus on provider reimbursement, claims processing, prior authorizations, referrals, and related business processes, partnering with business stakeholders, technical teams, and vendors to deliver system enhancements and operational improvements.
The ideal candidate will have a strong understanding of healthcare operations, claims management, prior authorization workflows, and the Software Development Life Cycle (SDLC). Experience with Medicaid, managed care, health plans, or healthcare payer systems is highly preferred.
Key Responsibilities
- Lead and participate in requirements gathering sessions, stakeholder interviews, and solution design workshops.
- Analyze and document business, functional, and system requirements for claims processing, prior authorization, referral management, and reimbursement initiatives.
- Conduct gap analysis and recommend process improvements to enhance operational efficiency and compliance.
- Collaborate with development, quality assurance, and business teams throughout the project lifecycle.
- Develop test strategies, test scenarios, and test cases based on documented requirements.
- Execute testing activities, validate results, and support user acceptance testing (UAT).
- Assist with release planning, implementation activities, and post-production stabilization efforts.
- Monitor system issues, support root cause analysis, and help develop corrective action plans.
- Partner with vendors and internal stakeholders to ensure solutions meet business requirements.
- Communicate project updates, system changes, and impacts to key stakeholders.
- Provide operational support and subject matter expertise related to claims, prior authorization, and referral workflows.
- Perform data analysis and reporting, including querying data to support business decisions and issue resolution.
- Create and maintain process documentation, training materials, and user guides.
Required Qualifications
- Bachelor's degree in Business, Information Technology, Healthcare Administration, or a related field; equivalent experience considered.
- 3 years of Business Analyst experience within healthcare, health insurance, managed care, or healthcare technology environments.
- Strong knowledge of Prior Authorization (PA), claims processing, referrals, and healthcare reimbursement processes.
- Experience gathering business requirements and supporting full SDLC projects.
- Understanding of Agile and/or traditional project methodologies.
- Strong analytical and problem-solving skills.
- Experience with data analysis and SQL queries.
- Excellent written and verbal communication skills.
- Ability to work independently and collaboratively with cross-functional teams.
- Experience facilitating meetings and communicating with both technical and business stakeholders.
Preferred Qualifications
- Experience supporting Medicaid, managed care, payer, or healthcare administration systems.
- Knowledge of HIPAA healthcare transactions and claims processing.
- Familiarity with healthcare interoperability standards and X12 transactions.
- Experience working with healthcare vendors and third-party technology partners.
- Demonstrated ability to analyze complex business processes and recommend effective solutions.