Business Analyst Healthcare claims

5+ years of business analysis or operations experience with direct, hands-on involvement in self-funded employer health plan administration — at a TPA, ASO, stop-loss carrier, or self-insured employer.
Deep working knowledge of self-funded plan mechanics: plan document structure, SPDs, benefit schedules, specific and aggregate stop-loss, funding arrangements, run-in/run-out periods, and terminal liability.
Strong understanding of payor-side claims operations: claims adjudication, COB, subrogation, repricing, network contract application, payment integrity, and EOB generation.
Familiarity with ERISA compliance requirements for self-funded plans, including plan document requirements, 5500 filings, SBC/SPD distribution, and fiduciary obligations.
Knowledge of ACA compliance requirements applicable to self-funded plans, including essential health benefits, preventive care mandates, out-of-pocket limits, nondiscrimination rules, and reporting (1094/1095-C).
Experience working with or analyzing utilization management (UM) programs, including prior authorization, concurrent review, case management, and discharge planning workflows.
Proven ability to document business requirements, user stories, BRDs, process flow diagrams, and functional specifications for operational or technology projects.
Experience working with claims management systems, benefits administration platforms, or TPA technology platforms.
Strong analytical skills: ability to interpret claims data, utilization reports, lag reports, and stop-loss specific claim tracking.
Excellent written and verbal communication skills; able to present complex plan mechanics clearly to employers, brokers, executives, and technical teams.
Bachelor's degree in Business, Healthcare Administration, Finance, Information Systems, or a related field.

 

Experience at a TPA, ASO, or third-party stop-loss carrier with direct involvement in plan implementation, renewal, or claims operations.
Knowledge of reference-based pricing (RBP), direct provider contracting, or alternative funding arrangements (captives, level-funded, MEWAs).
Familiarity with pharmacy benefit management (PBM) integration within self-funded plans: formulary, rebate structures, specialty Rx, and step therapy.
Understanding of mental health parity (MHPAEA) compliance requirements and comparative analysis documentation.
Experience with COBRA administration, retiree health plans, or HRA/HSA/FSA integration within self-funded plan structures.
Knowledge of EDI transactions (837/835/270/271/278) and HIPAA transaction standards.
Experience with Agile/Scrum methodology; proficiency with Jira, Confluence, or similar tools.
CEBS (Certified Employee Benefit Specialist), CBAP, or PMI-PBA certification strongly preferred.
Familiarity with AI-powered claims processing, payment integrity tools, or cost containment analytics.