Senior Business Analyst Position Summary

Hybrid – Onsite in the Philadelphia Tuesday, Wednesday, and Thursday

The Business Operations Analyst is responsible for developing and ensuring the accurate setup of medical and claim payment policies in alignment with business requirements. This individual will analyze claims data and trends to determine whether system enforcement is appropriate or requires adjustment, while also identifying opportunities for process improvement, system inconsistencies, and training needs.

Key Responsibilities

• Develop policy enforcement requirements based on medical and claim payment policy criteria. Enforcement types may include, but are not limited to, claim system edits, prior authorization workflows, desk-level procedures, and post-payment review.
• Partner with internal stakeholders to gain an understanding of policy criteria and medical coding rules in order to assess system capabilities.
• Collaborate with cross-functional departments and external vendors to ensure the accurate implementation of policies according to business requirements.
• Identify policies that require manual review when systematic enforcement is not feasible or recommended.
• Provide timely, documented feedback on issues identified at the system level and execute escalation procedures, including corrective action plans, as needed.
• Develop and review claims data utilization reports to ensure assigned policies are enforced according to business requirements.
• Review and resolve claims incidents resulting from policy setup issues, ensuring all impacted claims are identified, adjusted, and properly reported.
• Conduct root cause analysis to determine the source of policy setup issues and recommend corrective actions.
• Perform User Acceptance Testing (UAT) in collaboration with external vendors and internal stakeholders.
• Provide input to regulatory and oversight teams regarding compliance with requirements such as CMS guidelines, BlueCard processing rules, product rules, denial messaging, and member/provider liability.
• Build strong working relationships with associates and leadership across the organization, as well as with outside contractors, consultants, and vendor partners.

Qualifications

• Bachelor’s degree in a related field or equivalent work experience.
• Current coding certification such as CCS, CPC, RHIA, or RHIT is preferred but not required.
• Minimum of five years of experience in claims, operations, business analysis, or business requirements development.
• Ability to work independently, manage competing priorities, meet deadlines, and assess the urgency and criticality of issues.
• Strong time management skills with the ability to prioritize deliverables and communicate realistic timelines.
• Proficiency with Microsoft Office applications, including Excel, Word, PowerPoint, SharePoint, and Teams.
• Working knowledge of organizational workflows, business processes, and the end-to-end claims lifecycle.

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