Healthcare Business Analyst

10+ years of Healthcare Payer experience with 5+ years in Behavioral Health (Mental Health & Substance Use Disorders).

Seeking a seasoned Behavioral Health SME with strong Business Analyst and healthcare systems expertise to support payer transformation initiatives. The ideal candidate will have deep knowledge of Behavioral Health operations, end-to-end payer processes, and healthcare regulations, along with the ability to bridge business and technology teams.

Key Requirements:

• 10+ years of Healthcare Payer experience with 5+ years in Behavioral Health (Mental Health & Substance Use Disorders).
• Strong understanding of the end-to-end payer lifecycle:
• Eligibility & Enrollment
• Benefits Configuration
• Claims Processing & Adjudication
• Prior Authorization
• Care & Case Management
• Provider Management
• Appeals & Grievances
• Payment Integrity
• Deep knowledge of Behavioral Health regulations, including:
• MHPAEA (Mental Health Parity)
• Medicare & Medicaid BH programs
• HIPAA
• CMS and State-specific regulatory requirements
• NCQA/URAC standards
• Strong Business Analysis skills:
• Requirements gathering
• BRD/FRD/User Stories
• Process mapping
• Gap analysis
• UAT/SIT support
• Stakeholder management
• Experience with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare, or similar.
• Knowledge of healthcare transactions and interoperability standards:
• 837, 835, 834, 270/271
• HL7/FHIR
• Strong SQL, data analysis, and system integration understanding.

Preferred

• Experience with Commercial, Medicare, and Medicaid lines of business.
• Exposure to Behavioral Health care management, utilization management, and value-based care programs.
• Experience working on payer modernization, data, AI, or digital transformation initiatives.

Ideal Candidate

The ideal candidate will be a Behavioral Health payer SME who combines deep business process knowledge, regulatory expertise, system knowledge, and business analysis skills, with proven experience across:

Behavioral Health + Claims + Eligibility + Benefits + Care Management + Provider Operations + Regulatory Compliance + Payer Technology Platforms.

This person should be capable of driving both strategic business discussions and detailed system-level solution design discussions with equal effectiveness