Healthcare Claims Business Analyst – SME

Job not on LinkedIn

🔥 21 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $90k - $115k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Business Analyst

👻 Ghost score 0%

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InfoMC, Inc.

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1994

🏥 Healthcare

☁️ SaaS

🤝 B2B

Healthcare • SaaS • B2B

InfoMC, Inc. is a healthcare technology and services company that implements and supports enterprise care-management software (branded Incedo™ in the provided materials) for health plans and provider networks. The company focuses on enabling value-based care through modules such as care management, behavioral health, utilization management, CMS compliance, and employee assistance/work-life programs. InfoMC works with Medicare Advantage plans, managed Medicaid, managed behavioral health organizations, employee assistance programs, and accountable care organizations to help scale operations, improve member outcomes, and meet regulatory requirements.

📋 Description

• Serve as the internal and client-facing subject matter expert on healthcare claims operations, EDI transaction standards, and payer-side adjudication logic • Translate client payer workflows and claims processing requirements into business and functional specifications • Advise clients on claims intake, adjudication rules, coordination of benefits, appeals and grievances, and remittance processing • Identify gaps between client legacy processes and Incedo capabilities and escalate as applicable • Support claims data migration strategies, legacy-system crosswalks, and historical claims data validation • Lead requirements discovery sessions, workflow mapping, and gap analysis during client onboarding • Develop BRDs, functional specifications, data mapping templates, and EDI companion guides • Coordinate end-to-end X12 transaction testing with client EDI teams and clearinghouse partners • Facilitate user acceptance testing for claims processing scenarios • Document client-specific configurations, workflow decisions, and edge cases • Partner with Engagement Managers and Technical Leads to track milestones, escalate risks, and manage expectations • Maintain knowledge of CMS regulations, HIPAA standards, and state Medicaid requirements • Advise clients on CMS-0057-F, No Surprises Act timelines, and state prompt pay laws • Support Medicare Advantage, Medicaid managed care, and CHIP encounter data submission configuration • Monitor X12, ICD/CPT/HCPCS, and CMS NCCI updates affecting configurations • Develop training materials, job aids, and onboarding playbooks • Mentor junior implementation staff • Collaborate with Product and Engineering on enhancement requests and market requirements • Contribute claims best practices and lessons learned to the Implementation Playbook

🎯 Requirements

• Bachelor’s Degree in Health Information Management, Healthcare Administration, Computer Science, Business, or equivalent work experience • Minimum of 5 years of experience in a healthcare payer environment • Hands-on experience with HIPAA X12 EDI transactions including 834, 837P/I/D, 835, 270/271, 275, 276/277, and 278 • Experience with claims adjudication systems, clearinghouse relationships, and payer-side EDI trading partner onboarding • Familiarity with ICD-10, CPT, HCPCS Level II, revenue codes, and NCCI edits • Experience supporting software implementations or system migrations in a healthcare payer context • Ability to travel to client sites as needed, estimated up to 20% • This role is not eligible for sponsorship • Deep command of the end-to-end payer claims lifecycle • Functional mastery of HIPAA ASC X12 transaction sets and ability to read, interpret, and troubleshoot raw EDI files • Ability to conduct structured discovery sessions and translate requirements into technical specifications • Strong written communication skills for BRDs, data dictionaries, and process flow diagrams • Ability to manage multiple concurrent client engagements with minimal supervision • Ability to coordinate across internal teams and external stakeholders • Analytical rigor and attention to detail when validating EDI data and adjudication outcomes • Working knowledge of relational databases and SQL • Preferred: Medicare Advantage or Medicaid managed care claims operations experience • Preferred: CMS-0057-F electronic prior authorization knowledge • Preferred: No Surprises Act requirements familiarity • Preferred: utilization management or care management platform experience • Preferred: CPHQ, RHIT, RHIA, or equivalent healthcare informatics certification • Preferred: PMP certification • Preferred: SQL proficiency for claims data validation and ad hoc reporting • Preferred: healthcare IT vendor or SaaS implementation experience

🏖️ Benefits

• Generous compensation plan • Qualifying annual bonuses • Health, Dental, and Vision Plan • Weekly in-office yoga classes • Monthly lunch provided • Fresh fruit and dry snacks available daily • Life insurance • Short- and long-term disability • 401(k) retirement savings plan • Paid holidays and vacation • Gym on premises • Community volunteering opportunities • Remote-eligible work environment • Reasonable accommodations for individuals with disabilities

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