Job description

We are seeking a Senior Business Analyst to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations. About the Role: The Senior Business Analyst in Health Care Services plays a pivotal role in bridging the gap between clinical operations and technology solutions to enhance member care and organizational efficiency. This position is responsible for analyzing complex business processes, identifying areas for improvement, and designing effective strategies that align with healthcare regulations and standards. The role requires collaboration with cross-functional teams including clinical staff, IT professionals, and management to gather requirements and translate them into actionable project plans. The Senior Business Analyst will lead initiatives that drive data-driven decision-making and support the implementation of innovative healthcare solutions. Ultimately, this role ensures that business objectives are met while maintaining compliance and improving overall service delivery within the healthcare environment. Minimum Qualifications: • Associate's degree in Business Administration, Health Informatics, or a related field. • At least 4 years of experience as a Business Analyst within the healthcare industry. • Proficient knowledge of UB04 / CMS-1500 claim adjudication process, including Medicare and Medicaid reimbursement methodologies (i.e. Per Diem, PPS, FFS, APG, Capitation, etc.) required. • Must possess good understanding of claim adjudication process including ICD, CPT, HCPCS • Strong proficiency in business analysis tools and methodologies, including requirements gathering and process mapping. • Relevant experience may substitute for the educational requirement on a year-for-year basis. Preferred Qualifications: • Bachelor's degree in Health Administration, Public Health, or a related discipline. • Certification such as Certified Business Analysis Professional (CBAP) or Certified Healthcare Business Analyst (CHBA). • Experience with Electronic Health Record (EHR) systems and healthcare data analytics platforms. • Knowledge of healthcare quality improvement frameworks and member safety standards. • Experience working in agile project environments. Responsibilities: • Maintain data integrity of provider set-ups and reimbursement configurations, including timely updates and troubleshooting. • Load and implement practitioner, hospital, and ancillary contracts into the claims system, including amendments and claims testing. • Program and maintain pricing setups based on contract specifications across various care settings (e.g., inpatient, outpatient, ER). • Participate in client implementations, conversions, and internal/external meetings to support operational needs. • Create documentation for workflows and policies and mentor staff on complex contract configurations.

Requirements

Must-haves

Associate's degree in Business Administration, Health Informatics, or a related field.
At least 4 years of experience as a Business Analyst within the healthcare industry.
Proficient knowledge of UB04 / CMS-1500 claim adjudication process, including Medicare and Medicaid reimbursement methodologies (i.e. Per Diem, PPS, FFS, APG, Capitation, etc.) required.
Must possess good understanding of claim adjudication process including ICD, CPT, HCPCS
Strong proficiency in business analysis tools and methodologies, including requirements gathering and process mapping.
Relevant experience may substitute for the educational requirement on a year-for-year basis.
Maintain data integrity of provider set-ups and reimbursement configurations, including timely updates and troubleshooting.
Load and implement practitioner, hospital, and ancillary contracts into the claims system, including amendments and claims testing.
Program and maintain pricing setups based on contract specifications across various care settings (e.g., inpatient, outpatient, ER).
Participate in client implementations, conversions, and internal/external meetings to support operational needs.
Create documentation for workflows and policies and mentor staff on complex contract configurations.

Nice-to-haves

Bachelor's degree in Health Administration, Public Health, or a related discipline.
Certification such as Certified Business Analysis Professional (CBAP) or Certified Healthcare Business Analyst (CHBA).
Experience with Electronic Health Record (EHR) systems and healthcare data analytics platforms.
Knowledge of healthcare quality improvement frameworks and member safety standards.
Experience working in agile project environments.

Application prep

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Keywords to mirror

agile

Platform: adp-workforce-now
Effort: medium