Business Analyst – Claims Configuration

🔥 15 hours ago

🇺🇸 United States – Remote

💵 $92.9k - $132.7k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🧐 Business Analyst

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Lead, mentor, and provide day-to-day technical direction to a team of Claims Configuration Business Analysts • Serve as the senior configuration subject matter expert and trusted advisor for assigned CEF Claims Maintenance & Operations accounts • Review configuration analysis, solution designs, implementation plans, and validation results • Establish configuration practices, documentation standards, peer-review controls, and knowledge-transfer processes • Interact with clients, vendors, and internal business, product, development, testing, operations, finance, provider, member, and encounter teams • Lead requirements discussions, configuration reviews, issue-resolution sessions, defect triage, solution walkthroughs, and operational governance discussions • Translate technical findings into business impacts, options, risks, and recommendations • Own issues and enhancements from intake and analysis through implementation, validation, communication, and closure • Configure and support QNXT claims solutions across contracts, benefits, fee schedules, payment methodologies, capitation, business rules, claims adjudication logic, X12 transaction data requirements, and CARC/RARC processing • Translate Medicaid policy, contractual requirements, and operational needs into configuration specifications, business rules, design artifacts, and acceptance criteria • Assess impacts across claims adjudication, pricing, benefits, provider reimbursement, encounters, remittance, financial processing, reporting, and downstream integrations • Determine root causes across configuration, data, policy interpretation, user processing, interfaces, product functionality, and dependencies • Write and execute complex SQL queries to analyze claims and related healthcare data • Perform claim-level and population-level root cause analysis for denials, pends, edits, payment issues, duplicates, encounter rejections, and other anomalies • Quantify impacted claims and populations, document evidence, compare expected and actual results, and recommend corrective actions • Support production incidents, client inquiries, audits, configuration defects, data fixes, and ad hoc reporting • Validate configuration changes through data analysis, claims testing, regression review, and post-implementation monitoring • Coordinate production support, priority issue resolution, scheduled releases, and multiple client and internal teams

🎯 Requirements

• 9+ years of hands-on, highly proficient QNXT configuration experience • Demonstrated depth in contracts, benefits, fee schedules, multiple payment methodologies, capitation, rules, successful data points for X12 transactions, and CARC/RARC processing • Thorough understanding of relational database concepts, healthcare data models, schemas, keys, and data relationships • Competency writing complex SQL queries for claims analysis, validation, troubleshooting, root cause analysis, and reporting • Strong knowledge of Medicaid claims processing, claims adjudication, provider reimbursement, benefit administration, edits, pricing, and encounter processing • Experience analyzing X12 healthcare transactions, including 837 and 835 transaction data and associated remittance adjustment reason codes • Ability to independently analyze complex claim scenarios, identify root cause, assess impact, and develop actionable business and configuration solutions • Experience leading or mentoring Configuration Business Analysts and reviewing technical or functional work products • Strong client-facing communication, facilitation, presentation, documentation, and stakeholder-management skills • Experience working within SDLC, Agile delivery, testing, release management, and production-support environments • Bachelor’s degree in Computer Science, Information Systems, Health Informatics, Business Administration, or a related field, or an equivalent combination of education and relevant experience • Experience supporting Medicaid claims configuration in a multi-account CEF Maintenance & Operations environment • Knowledge of CMS guidance, state Medicaid policy, MITA, encounter processing, financial reconciliation, and compliance considerations • Experience with IT service management and work-tracking tools such as ServiceNow, Jira, or similar platforms • Ability to balance client priorities, production risk, operational urgency, and long-term configuration sustainability • Video cameras must be used during all interviews and during the initial week of orientation • Stable internet connection and quiet location for screenings, interviews, and meetings

🏖️ Benefits

• Work flexibility • Learning and career development • Generous, flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies • Equal Opportunity Employer