Technical Business Analyst - IT Healthcare

Job Overview

This role involves working closely with clinical teams, business stakeholders, and IT departments within the healthcare payer sector to analyze, document, and drive implementation of both business and technical requirements.

Key Responsibilities

• Bridge communication between software development groups and business users to improve healthcare payer systems and processes.
• Review and interpret healthcare policies, claims workflows, and coding standards to suggest effective technical and business solutions.
• Support key healthcare programs including medical review, appeals, compliance, and program integrity.
• Apply knowledge of ICD, CPT, and HCPCS coding to enhance business practices and system functionalities.
• Conduct detailed business process and gap analyses, including workflow documentation and comprehensive requirements gathering for healthcare IT projects.
• Collaborate actively with developers, quality assurance specialists, and project management through all phases of the SDLC.
• Verify system performance and conduct user acceptance testing to ensure requirements alignment.
• Audit healthcare claims, coding techniques, and reimbursement policies to maintain compliance and operational correctness.
• Utilize medical coding and claims processing software for processing data and providing business insights.
• Create thorough business documentation such as functional specs, process diagrams, requirement statements, and manuals.
• Support initiatives related to policy remediation and ongoing operational improvements.
• Engage with cross-functional teams to address and resolve complex technical and business challenges.
• Ensure full compliance with healthcare regulations, coding standards, and organizational guidelines.
• Serve as a subject matter expert on payer operations and clinical business workflows.

Required Qualifications

• Certification in ICD-10 proficiency or the commitment to achieve this within the first year of employment.
• Minimum of 10 years’ experience within healthcare insurance domains such as medical review, program integrity, or appeals.
• At least 5 years collaborating with IT developers on healthcare payer projects.
• Five years of hands-on medical coding experience specific to payer environments.
• Three or more years of clinical experience demonstrating strong assessment and critical thinking competencies.
• Extensive familiarity (5+ years) with ICD, CPT, and HCPCS coding systems and translation practices.
• Strong foundation in anatomy, physiology, pharmacology, and medical terminology, with over 5 years experience.
• Five years supporting policy remediation efforts and using healthcare claims processing systems.
• Proficiency with Microsoft Office tools at a professional level for at least 5 years.
• Experience using Optum Encoder or similar medical coding software for a minimum of 5 years.
• Holder of a Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN).
• Active, unrestricted Registered Nurse (RN) license from the State of South Carolina.
• Certification as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).

Preferred Skills

• Exceptional analytical thinking and problem-solving capabilities.
• Strong written and oral communication skills.
• Experience in detailed requirements gathering and documentation tailored for healthcare IT projects.
• Good understanding of healthcare payer operations, claims adjudication, and reimbursement methods.
• Proficient in navigating both Agile and Waterfall project management environments.
• Ability to prioritize multiple tasks efficiently while fostering collaborative relationships between technical and business stakeholders.