Job Summary
We are seeking a highly experienced Lead Claims Business Analyst to support a large-scale Core Processing System transformation. This role focuses on medical and behavioral health claims processing across government and commercial lines of business (Medicaid, Medicare, CHP, QHP).
The ideal candidate will lead requirements gathering, process analysis, system implementation, testing, and training, while translating current-state workflows into optimized future-state solutions. This role requires strong collaboration with consultants, leadership, and cross-functional teams to ensure a seamless system transition and improved claims operations.
Key Responsibilities
• Act as the primary point of contact for the Claims Processing workstream
• Lead requirements gathering, stakeholder interviews, and documentation (business, functional, workflows, reporting)
• Analyze current-state vs. future-state workflows and identify gaps, inefficiencies, and improvement opportunities
• Partner with stakeholders to design and implement optimized claims processes and system enhancements
• Ensure alignment with health plan regulations, compliance requirements, and business objectives
• Collaborate with QA teams to define test cases, scenarios, and acceptance criteria
• Support UAT, system validation, and issue resolution during implementation
• Assist in training material development and end-user training sessions
• Monitor project progress, manage deliverables, and communicate updates to stakeholders
• Act as a liaison between business, IT, and leadership teams
Required Qualifications
• Bachelor’s degree in Business, Healthcare, or related field (or equivalent experience)
• 5+ years of experience as a Business Analyst in healthcare claims processing
• Strong knowledge of medical claims operations (Medicaid, Medicare, Commercial)
• Experience with core claims system implementation or migration
• Expertise in requirements gathering, workflow documentation, and process improvement
• Experience with UAT, QA, and system validation
• Knowledge of provider networks, fee schedules, and claims regulations
• Strong analytical, communication, and stakeholder management skills
• Proficiency in MS Office (Excel, Visio, PowerPoint, Word)
Pride Health offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k) retirement savings, life & disability insurance, an employee assistance program, legal support, auto and home insurance, pet insurance, and employee discounts with preferred vendors.