Team: Analyst
This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Lead Business Analyst – Claims Payment Integrity in the United States.
In this role, you will lead high-impact business analysis initiatives focused on improving claims payment accuracy and operational efficiency across healthcare programs. You will collaborate with cross-functional teams to identify revenue opportunities, investigate root causes of payment discrepancies, and translate complex healthcare policies into actionable business rules. This position plays a key role in supporting payment integrity initiatives across Medicare, Medicaid, and commercial markets while guiding analytical teams and influencing strategic decision-making. You will work with large, multi-source healthcare datasets and partner with operational, actuarial, and technical stakeholders to deliver measurable financial and operational outcomes. Ideal candidates bring strong healthcare domain expertise, advanced analytical capabilities, and the ability to drive cross-functional collaboration in complex environments.
Accountabilities:
Lead end-to-end business analysis efforts across claims adjudication, payment integrity reviews, audit recovery, appeals, and fraud, waste, and abuse (FWA) investigationsIdentify revenue and cost-saving opportunities by analyzing duplicate claims, pricing errors, eligibility discrepancies, and other payment leakage sourcesAct as the primary liaison between business sponsors, payment integrity SMEs, actuarial teams, provider operations, and technical delivery teamsTranslate healthcare policies, benefit structures, contract terms, and payment guidelines into clear business rules and functional requirementsDevelop and refine requirements, business rule logic, and acceptance criteria for payment integrity initiatives and system enhancementsAnalyze data quality, perform financial impact assessments, and validate projections related to payment integrity programsMentor and guide Business Analysts, ensuring consistent analytical standards, documentation quality, and best practicesConduct deep-dive investigations into claim-level patterns, provider anomalies, pricing discrepancies, and eligibility mismatchesSupport leadership reporting, audit responses, regulatory documentation, and operational performance reviewsParticipate in roadmap planning, initiative prioritization, and cross-functional strategy discussionsRequirements
Bachelor’s degree in Business, Health Administration, Finance, or a related field8+ years of Business Analysis experience within the U.S. healthcare industryStrong understanding of claims adjudication, payment policies, benefit design, and healthcare reimbursement modelsDemonstrated leadership in cross-functional collaboration and stakeholder managementExperience interpreting healthcare guidelines and translating them into functional business requirementsExcellent analytical, problem-solving, and decision-making capabilitiesExperience facilitating workshops, requirements sessions, and cross-functional planning meetingsStrong written and verbal communication skills with the ability to present insights to leadershipAbility to manage multiple priorities while maintaining attention to detail and analytical rigorFamiliarity with call center datasets for member/provider interactions and service navigation insightsExperience working with provider revenue cycle management (RCM) data, billing patterns, and clinical documentation alignmentExposure to EHR or clinical datasets to validate medical necessity and care patternsKnowledge of payment integrity reporting including duplicate claim detection, pricing anomalies, and eligibility mismatchesPreferred Qualifications
Experience in Claims Payment Integrity, FWA programs, provider contracting, billing, or revenue cycle operationsDeep knowledge of Medicare and Medicaid programsSQL skills for data analysis, validation, and reportingFamiliarity with PBM systems, eligibility logic, or provider credentialing platformsBenefits
Competitive contract compensation packageFully remote work environment within the United StatesOpportunity to lead high-impact initiatives improving healthcare payment accuracy and operational performanceExposure to large-scale healthcare datasets and advanced analytical projectsCollaborative environment working with actuarial, operational, and technical stakeholdersProfessional development opportunities within healthcare analytics and payment integrity programsFlexible work structure supporting work-life balance