Lead Business Analyst

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Position: Lead Business Analyst - Claims Payment Integrity (Healthcare exp must need)

Contract/Full Time

Remote

Role Summary

The Lead Business Analyst provides strategic and operational leadership for business analysis initiatives supporting Claims Payment Integrity (PI) across Medicare, Medicaid, Commercial & Employer markets. The role drives revenue impact identification, root-cause analysis, and business rule translation, while guiding analysts and influencing stakeholders across operational, actuarial, and technical teams.

This role requires deep domain expertise, strong analytical judgment, leadership in cross-functional problem solving, and an ability to work across multi-source healthcare datasets.

Key Responsibilities

• Lead end-to-end business analysis efforts across claims adjudication, payment integrity reviews, appeals, audit recovery, and FWA investigations.
• Drive revenue-based opportunity identification, including duplicate claims detection, pricing/contract errors, eligibility misalignment, underpayment/overpayment root causes, and leakage prevention.
• Serve as the primary liaison between business sponsors, PI SMEs, actuarial partners, provider teams, and technical build teams.
• Interpret healthcare guidelines, policies, contract rules, and benefit logic and translate them into actionable business rules and functional requirements.
• Lead formulation, validation, and refinement of requirements, acceptance criteria, and business rule logic for PI interventions.
• Review data quality, impact assessments, and financial projections across PI initiatives.
• Mentor and guide Business Analysts, ensuring consistency, analytical rigor, and adherence to documentation standards.
• Lead complex issue remediation: deep-dives into claim-level patterns, provider-level anomalies, pricing variances, member eligibility mismatches, and systemic process gaps.
• Support leadership-level reporting, audit responses, regulatory inquiries, and controls documentation.
• Participate in roadmap design, prioritization sessions, operational reviews, and cross-functional working groups.

Domain & Data Expertise (Required)

• Familiarity with Call Center datasets (member & provider contact/call data) for identifying navigation issues, provider abrasion signals, or member experience indicators tied to PI.
• Experience working with Provider RCM data (billing patterns, coding, prior auth, clinical documentation alignment).
• Exposure to EHR / Clinical datasets for validating medical necessity, care patterns, and crosswalks to claims.
• Experience with PI-specific reporting, including:
• Duplicate claim identification
• Pricing anomalies
• Eligibility issues & benefit mismatches
• Understanding of actuarial reporting, forecasting dashboards, or cost-of-care analytics used for PI impact sizing.

Required Qualifications

• Bachelor's degree in Business, Health Administration, Finance, or related field
• 8+ years of Business Analysis experience in Healthcare (Onshore)
• Strong leadership, decision-making, and stakeholder management skills
• Excellent analytical and problem-solving skills
• Proven experience interpreting claims adjudication rules, payment policies, or benefit structures
• Experience facilitating cross-functional workshops, JAD sessions, and requirements reviews
• Exceptional written and verbal communication
• Strong time management; ability to handle multiple priorities
• Proven ability to work independently and collaboratively

Preferred Qualifications

• Experience in Claims PI, FWA, Provider Contracting, Billing, or RCM
• Medicare / Medicaid domain depth
• SQL for data exploration, validation, and reporting
• Familiarity with PBM, eligibility logic, or provider credentialing systems

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