Business Analyst - US Medical Insurance Domain (Remote)

Job Title: Business Analyst – Medical Insurance Domain

Location: Remote

Working Hours: 6 PM to 3 AM IST (night shift)

Experience Required: Minimum 3 years

Employment Type: Full-Time

Department: Healthcare Operations / IT & Compliance

Position Overview

The Business Analyst (BA) will play a key role in analysing, designing, and improving healthcare payer operations and reporting systems. The ideal candidate should have a strong understanding of the medical insurance ecosystem, including claims lifecycle, regulatory reporting (CMS/DHS), and interoperability standards. The BA will act as a bridge between business stakeholders, data teams, and technical developers to ensure accurate, compliant, and efficient data-driven processes.

Key Responsibilities

• Analyse, document, and improve end-to-end claims processing workflows (Professional, Institutional, and Encounter claims).
• Design and develop business requirement documents (BRDs), functional specifications, and data mapping documents (source-to-target).
• Work closely with product owners and developers in Agile/Scrum environments to define user stories, acceptance criteria, and sprint deliverables.
• Support regulatory and compliance reporting by generating and validating reports aligned with CMS, DHS, and other healthcare agency standards.
• Utilise SQL to perform data analysis, extract insights, and validate report outputs from production and data warehouse systems.
• Collaborate with data engineering teams to define and validate ETL workflows, ensuring correct data transformation and integration across systems.
• Understand and interpret interoperability frameworks such as FHIR, HL7, X12 (837/835/270/271), and 278 for healthcare data exchange.
• Coordinate with QA and UAT teams to ensure business and technical requirements are met with accuracy and compliance.
• Communicate effectively with both technical and non-technical stakeholders to translate business needs into actionable requirements.

Required Skills and Qualifications

• Bachelor’s degree in Computer Science, Information Systems, Healthcare Informatics, or a related field.
• 3+ years of experience as a Business Analyst within the healthcare payer or insurance industry.
• In-depth knowledge of medical claims processing, including adjudication, encounters, and reporting.
• Strong hands-on experience with SQL (joins, aggregations, report generation).
• Experience with CMS and DHS regulatory reporting (e.g., ODAG, CDAG, HEDIS, PDR, MOOP, CMS-0057-F, etc.).
• Proficient in creating Source-to-Target Mapping (STM) documents for data migration or integration.
• Knowledge of ETL processes, data warehousing, and reporting tools (e.g., Power BI, Tableau, SSRS).
• Working understanding of interoperability standards (FHIR, HL7, X12 EDI transactions).
• Strong analytical, documentation, and communication skills.
• Experience with Agile/Scrum methodologies, JIRA, or similar tools.

Preferred Qualifications

• Experience with payer systems such as EPIC, MHK, QNXT, HealthEdge, or Epic Tapestry.
• Exposure to Snowflake, Azure Data Factory, or other cloud-based data environments.
• Familiarity with HIPAA and data privacy standards.
• Experience supporting regulatory audits and data validation for CMS submissions.

Soft Skills

• Strong problem-solving and critical-thinking abilities.
• Excellent verbal and written communication for stakeholder management.
• Ability to work independently and collaboratively in fast-paced environments.
• Detail-oriented with a focus on data accuracy and compliance.