Healthcare Claims Business Analyst (Payment Integrity)

Quick Facts

• Focus: U.S. Healthcare Payment Integrity and end-to-end claims processing analysis
• Seniority: 10+ years Business Analysis / Business Systems Analysis

Description

Serve as a business analysis and solution design expert for Payment Integrity across the full claims lifecycle—from pre-adjudication prevention to prepay interventions and postpay auditing/overpayment recovery. Elicit and document complex requirements, translate payment policies and clinical/reimbursement rules into workflows and actionable business rules, and support investigations with clear evidence and audit trails. Use root-cause analysis to reduce recurring leakage by shifting controls upstream.

Responsibilities

• Elicit, analyze, and document complex business, operational, and system requirements for claims and Payment Integrity
• Translate business problems into functional requirements, workflows, process models, and user stories
• Analyze the end-to-end Payment Integrity lifecycle (pre-submission/pre-adjudication prevention through continuous improvement)
• Support pre-adjudication and front-end prevention by converting policies, coding/reimbursement guidance, eligibility rules, and provider-facing error-prevention needs into business rules, alerts, and messaging
• Analyze prepay capabilities such as automated/manual claim edits, analytical claim selection, clinical/non-clinical reviews, medical-record and itemized-bill validation, correct-coding and payment-policy checks, and routing/intervention outcomes (allow/adjust/hold/pend/deny)
• Support postpay and recovery workflows: retrospective audits, investigation, claim adjustments and recovery coordination, and resolution tracking with audit trails
• Perform root-cause analysis on postpay findings, appeals, adjustments, recovery results, and repeat billing patterns to shift recurring leakage upstream
• Apply cross-cutting Payment Integrity knowledge: waste and error, clinical PI, facility audit, claims cost management, payment policy, audit and recovery, Fraud/Waste/Abuse, COB, subrogation, payment primacy, and avoided-spend initiatives
• Analyze COB, subrogation, and payment-primacy scenarios for accurate identification of primary coverage and payer responsibility
• Evaluate PI scenarios across commercial, Medicare, Medicaid, ASO, and other lines of business, considering claim type, professional vs facility billing, reimbursement methodology, provider behavior, member eligibility/utilization context, regulatory needs, and clinical vs non-clinical review requirements

Requirements

• 10+ years of Business Analysis / Business Systems Analysis experience
• Strong U.S. Healthcare experience across all Lines of Business
• Payment Integrity and claims processing experience, including end-to-end claim lifecycle knowledge
• Claim Processing and Claim Auditing experience (required)
• Experience analyzing the Payment Integrity lifecycle: prepay prevention, prepay interventions, postpay audit, overpayment recovery, and continuous improvement
• Experience supporting pre-adjudication/front-end prevention by translating policies, coding/reimbursement guidelines, eligibility rules, and provider error-prevention requirements into actionable workflows/rules
• Experience analyzing prepay capabilities (edits, analytical selection, clinical/non-clinical reviews, validation, routing outcomes)
• Experience supporting postpay and recovery workflows with retrospective audit/investigation, adjustments/recovery coordination, and audit-trail maintenance
• Ability to perform root-cause analysis to shift recurring leakage upstream
• Working knowledge of cross-cutting PI capabilities including Fraud/Waste/Abuse, COB, Subrogation, and Payment Primacy
• Experience evaluating PI scenarios across commercial, Medicare, Medicaid, ASO (and other applicable lines of business)