Business Analyst/ Claims SME

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

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
• 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