Business Analyst, Claims (Onsite 3 Days/Week)

The Business Analyst, Claims supports health plan claims operations by investigating complex claims issues, analyzing data, and driving process improvements. Working closely with Claims Operations and cross-functional teams, this role identifies root causes, supports system enhancements, and helps ensure claims are processed accurately, efficiently, and in compliance with regulatory requirements. We encourage candidates with experience in managed care claims, claims auditing, claims processing, or appeals & grievances to apply.

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.

What You Will Do

• Investigate complex claims issues and identify root causes.
• Analyze paid, denied, and pended claims to ensure accurate adjudication.
• Review provider disputes and resolve claims within established service level agreements.
• Manage claims analysis projects ranging from individual claims to large claim populations.
• Identify trends and recommend process improvements to improve claims accuracy and efficiency.
• Collaborate with Claims Operations, Configuration, Eligibility, Credentialing, and other business partners to resolve claims issues.
• Gather business requirements and support system enhancements and testing activities.
• Audit processed claims and recommend corrective actions when needed.
• Analyze claims data and prepare reports to support operational decision-making.
• Perform financial impact analyses related to reimbursement and payment changes.
• Manage workload to meet departmental goals and service level expectations.
• Participate in cross-functional initiatives and special projects.

Education:

• Bachelor's Degree in Business or related discipline or the equivalent work experience, required
• Master's Degree in Business Administration, Public Administration or related field, preferred

Work Experience:

• Two years' experience with claims in a healthcare setting required. Experience with managed care claims preferred.
• A year of experience with a managed care organization on business transformation required
• Two years' experience using FACETS, SQL scripts & queries, OBIEE, Power BI, Tableau & MicroStrategy reports & dashboards; project management & SDLC methodologies, with contracting and new business management across relational databases, using Oracle, SQL Server & DB2, managing stakeholder expectations and providing HIPAA-compliant guidance to business partners, vendors, and end-users, per industry standards for EDI protocols preferred
• Strong command of Microsoft Office Tools (Word, Excel, Visio, and PowerPoint) required
• Effective oral and written communication skills, consulting and analytical skills and ability to work with clients, IT management, staff, consultants and vendors required
• Ability to function autonomously, and collaborate with most senior level leaders across the agency required
• Demonstrated understanding of NYS, CMS and Medicare & Medicaid reimbursement guidelines. APG, APC, DRG required