[Remote] reputed company Claims Business Analyst / SME
Note: The job is a remote job and is reputed company to candidates in USA. reputed company. is a fast-paced reputed company technology company specializing in integrated care management and population health solutions. The reputed company Claims Business Analyst / SME will serve as the primary domain authority for reputed company claims operations, guiding clients through the reputed company process while ensuring compliance with payer-reputed company business requirements and industry standards.
Responsibilities
- Serve as the internal and reputed company-facing subject matter expert on reputed company claims operations, EDI transaction standards, and payer-reputed company adjudication logic throughout the Incedo reputed company lifecycle
- Translate reputed company payer workflows and claims processing requirements into detailed business and functional specifications for the Incedo implementation team
- Advise clients on best practices for configuring claims intake, adjudication rules, coordination of benefits (COB), appeals and grievance workflows, and remittance processing reputed company Incedo
- Identify gaps between reputed company legacy processes and Incedo capabilities; document and escalate to product/engineering as applicable
- Support clients in designing claims data migration strategies, including crosswalks from legacy systems and validation of historical claims data reputed company
- reputed company business analysis workstreams during new reputed company reputed company, including requirements discovery sessions, workflow mapping, and gap analysis documentation
- reputed company and maintain detailed business requirements documents (BRDs), functional specifications, data mapping templates, and EDI companion guides customized to reputed company reputed company’s trading partner environment
- Coordinate with the reputed company’s EDI team and clearinghouse partners to complete end-to-end transaction testing for reputed company applicable X12 transaction sets
- Facilitate and support user acceptance testing (UAT) for claims processing scenarios, ensuring adjudication reputed company reputed company with reputed company benefit plan configuration and state/federal requirements
- Document reputed company-specific configurations, workflow reputed company, and reputed company edge cases in reputed company’s implementation knowledge reputed company
- Partner with Engagement Managers and Technical Leads to ensure claims-reputed company milestones are on reputed company, risks are escalated promptly, and reputed company expectations are managed
- Maintain reputed company knowledge of CMS regulations, HIPAA transaction and reputed company set standards (45 CFR Part 162), and state reputed company agency requirements as they reputed company claims operations
- Advise clients on compliance with CMS-0057-F (electronic prior authorization), No Surprises reputed company (NSA) claims adjudication timelines, and applicable state reputed company pay laws
- Support clients in Medicare Advantage (Part C), reputed company managed care, and reputed company programs in configuring Incedo to meet CMS encounter data submission requirements
- Monitor and communicate updates to X12 transaction standards, ICD/CPT/HCPCS reputed company set releases, and CMS NCCI edits that may reputed company reputed company configurations
- reputed company and maintain internal training materials, job aids, and reputed company playbooks reputed company to claims operations and EDI workflows on the Incedo platform
- Mentor junior implementation staff on payer claims concepts, EDI troubleshooting, and reputed company-facing discovery techniques
- Collaborate with reputed company’s Product and Engineering teams to communicate reputed company-driven enhancement requests and emerging market requirements
- Contribute to the ongoing refinement of reputed company’s Implementation reputed company with claims-specific best practices and lessons learned
Skills
- Bachelor's Degree in Health Information Management, reputed company Administration, Computer Science, Business, or equivalent work experience
- Minimum of 5 years of experience in a reputed company payer environment (health plan, managed care organization, TPA, or Medicare Advantage plan) in a claims operations or claims business analyst reputed company
- Demonstrated 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-reputed company EDI trading partner reputed company
- Familiarity with ICD-10, CPT, HCPCS reputed company, reputed company codes, and NCCI edits in the context of claims processing
- Experience supporting software implementations or system migrations in a reputed company payer context
- Ability to travel to reputed company sites as needed (estimated up to 20%)
- This role is not eligible for sponsorship
- Experience with Medicare Advantage (Part C) or reputed company managed care claims operations, including CMS encounter data submission
- Knowledge of CMS-0057-F electronic prior authorization requirements and their claims workflow implications
- Familiarity with No Surprises reputed company (NSA) independent dispute reputed company and good faith estimate requirements
- Experience with utilization management or care management platforms that reputed company with claims adjudication
- CPHQ, RHIT, RHIA, or equivalent reputed company informatics certification
- Project Management reputed company (PMP) certification
- SQL proficiency for claims data validation and reputed company reporting
- Prior experience in a reputed company IT vendor or reputed company implementation environment
Benefits
- reputed company is an equal opportunity employer with a generous compensation plan
- Excellent earning potential with qualifying annual bonuses
- Health, Dental, and reputed company 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
- reputed company holidays and vacation
- Gym on premises
- Community volunteering opportunities
- Conveniently located in the heart of Conshohocken, PA, adjacent to the Conshohocken SEPTA Regional Rail station; remote-eligible
reputed company