Healthcare Business Systems Analyst

We are seeking an experienced Healthcare Business Systems Analyst (BSA) with strong knowledge of healthcare claims processing and pre-adjudication workflows. The ideal candidate will have hands-on experience analyzing healthcare EDI transactions, claim intake and validation processes, and the flow of claims from trading partners through pre-adjudication and into the core claims adjudication system. Key Responsibilities * Analyze and document end-to-end healthcare claim workflows, with a strong focus on pre-adjudication processing. * Work extensively with 837 Professional (837P) and Institutional (837I) claim transactions. * Understand the claim lifecycle from provider/trading partner → clearinghouse/gateway → EDI/pre-adjudication platform → core adjudication system. * Analyze pre-adjudication processes including: * File and transaction validation * HIPAA/X12 compliance validation * Trading partner and submitter validation * Member and provider validation * Duplicate and business-rule validations * Claim balancing and control totals * Claim acceptance/rejection * Error handling and exception processing * Strong understanding of 999 Functional Acknowledgment and 277CA Claim Acknowledgment transactions and their relationship to 837 processing. * Analyze rejected claims and identify whether issues originate from the trading partner, EDI/pre-adjudication layer, mapping/transformation logic, or downstream claims system. * Gather and translate business requirements into business requirements, functional requirements, user stories, process flows, mapping documents, and acceptance criteria. * Conduct requirements-gathering sessions with business, EDI, claims operations, development, testing, and vendor teams. * Perform gap analysis and impact analysis for new implementations and changes to existing claim-processing workflows. * Support SIT/UAT by developing test scenarios, reviewing test results, validating claim outcomes, and assisting with defect analysis. * Work closely with technical teams to troubleshoot production issues involving claim intake, validation, rejection, and downstream processing. Required Qualifications * 5+ years of Business Systems Analyst experience, preferably within healthcare payer environments. * Strong hands-on knowledge of healthcare claims and pre-adjudication processes. * Strong understanding of HIPAA X12 EDI transactions, particularly: * 837P * 837I * 999 * 277CA * Good understanding of Professional and Institutional claims and associated claim and service-line data. * Experience working with Medicaid and/or Medicare managed care environments preferred. * Understanding of the distinction between pre-adjudication edits/rejections and claims adjudication edits/denials. * Experience documenting as-is/to-be workflows, business rules, functional requirements, user stories, and acceptance criteria. * Strong analytical and troubleshooting skills, including the ability to trace claims across multiple systems. * Experience with SQL/data analysis for claim research and validation is highly preferred. * Experience working in Agile/Scrum environments and Jira is preferred. Preferred Experience Experience with healthcare payer core administration and EDI platforms such as Facets or similar claims systems, EDI gateways/translators, clearinghouses, and claim intake/pre-adjudication applications is highly desirable. Primary Skill: Healthcare BSA – Claims Pre-Adjudication Secondary Skills: 837P/837I, 999, 277CA, HIPAA X12, Claims Processing, Requirements Analysis, SQL, Jira Industry: Healthcare Payer / Medicaid / Medicare