Healthcare Analyst - Claims/payment integrity

<>Main Areas : Experience specifically focused on claims process and hands on experience with payment integrity, payment and RCM processes

Key Responsibilities
Business Analysis & Solution Design
•    Elicit, analyze, and document complex business, operational, and system requirements
•    Translate business problems into functional requirements, workflows, process models, and user stories
•    Facilitate requirements workshops with business and technology stakeholders
•    Support end-to-end solution design and implementation activities
•    Validate that delivered solutions meet business objectives and acceptance criteria
Payment Integrity & Healthcare Domain Analysis
•    Analyze healthcare claims, provider billing patterns, member utilization, and payment integrity opportunities
•    Support initiatives focused on preventing improper payments and reducing financial leakage
•    Collaborate with SMEs to understand clinical and non-clinical claim scenarios
•    Perform root cause analysis and identify process improvement opportunities
AI  & Intelligent Automation Enablement
•    Translate business risks and operational challenges into AI-ready business requirements
•    Define business rules, signals, thresholds, and intervention logic supporting AI-enabled workflows
•    Partner with Data Science teams to define model inputs, outputs, business validation criteria, and success measures
•    Support Human-in-the-Loop review processes and AI governance practices
•    Participate in workflow automation and intelligent decision-support initiatives
•    Ensure AI-driven solutions remain explainable, auditable, and aligned with business objectives
Data & Analytics Support
•    Analyze large healthcare datasets to identify trends, anomalies, and improvement opportunities
•    Collaborate with analytics teams to define metrics, KPIs, and reporting requirements
•    Support business validation and testing efforts
•    Leverage data to support strategic decision making
Stakeholder Engagement
•    Serve as liaison between business, operations, product, engineering, data science, and analytics teams
•    Facilitate discussions, alignment sessions, and solution reviews
•    Present recommendations and findings to leadership and stakeholders
•    Drive consensus across cross-functional teams
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Preferred Experience
•    10+ years of Business Analysis / Business Systems Analysis experience
•    Strong U.S. Healthcare experience working with all Lines of businesses
•    Payment Integrity, Claims, FWA/Revenue Cycle Management experience
•    Experience supporting AI, advanced analytics, or intelligent automation initiatives
•    Healthcare claims processing and adjudication knowledge
o    Knowledge of lifecycle of a claim is a “MUST”. Claims processing is an added advantage
•    Agile delivery experience
•    SQL and data analysis capabilities
•    Experience working with Databricks, Snowflake, Tableau, or Power BI preferred