Note: The job is a remote job and is open to candidates in USA. ICONMA is seeking a Business Analyst to support healthcare payer claims systems and operations. The role focuses on requirements elicitation, claims lifecycle analysis, FEP-specific processing, data mapping, testing, regulatory releases, production support, and Agile delivery.
Responsibilities
- Elicit and document business/functional requirements for claims adjudication, pricing, and payment systems — BRDs, FRDs, user stories with acceptance criteria, business rules, and traceability matrices
- Analyze the end-to-end claims lifecycle (intake → EDI → edits → pend resolution → adjudication → pricing → COB → payment → remittance) and drive gap closure and automation
- Own FEP-specific requirements: FEP Direct/Express workflows, FEP Blue Standard/Basic/Focus benefit structures, annual brochure benefit changes, and FEP Operations Center files and reporting
- Translate OPM/FEHB guidance and carrier letters into system requirements and configuration change requests
- Perform source-to-target data mapping for X12 transactions (837, 835, 834, 270/271, 276/277, 278) and proprietary claim layouts
- Document and validate claims business rules: accumulators, benefit limits, authorization matching, timely filing, duplicate logic, contract pricing, and edit dispositions
- Write SQL to profile claims data, validate adjudication outcomes, and perform root-cause analysis on production defects
- Define test scenarios and lead SIT/regression/UAT cycles, defect triage, and business sign-off
- Lead requirements for mandate and regulatory releases (CMS updates, No Surprises Act, annual ICD-10/CPT/HCPCS code updates)
- Support production escalations: payment discrepancies, adjustments/voids, overpayment recovery, provider/member issues
- Drive Agile ceremonies with the Product Owner — backlog grooming, prioritization, sprint planning, reviews
- Prepare audit deliverables for internal, OPM, and CMS reviews; mentor junior analysts and act as claims/FEP domain SME
Skills
- Bachelor's degree in IT, Computer Science, Health Informatics, Business, or related field
- 8+ years as an IT/Business Systems Analyst in the healthcare payer domain
- 5+ years hands-on with claims processing and adjudication systems
- 3+ years direct FEP claims processing experience — FEP Direct/Express, FEP Blue plan structures, OPM/FEHB rules, FEP reporting cycles
- Hands-on experience with an enterprise claims platform: Facets, QNXT, HealthEdge HealthRules, NASCO, Amisys, or equivalent
- Working knowledge of HIPAA X12 5010 transactions: 837, 835, 834, 270/271, 276/277, 278
- Knowledge of ICD-10, CPT, HCPCS, DRG, revenue codes, modifiers, NDC, NPI, CMS-1500, UB-04
- Experience with COB/TPL, Medicare crossover, and subrogation rules
- Intermediate-to-advanced SQL for data analysis and validation
- Proven Agile/Scrum delivery experience with Jira, Azure DevOps, or Rally
- Strong process modeling skills (Visio, Lucid chart, BPMN) and audit-ready documentation discipline
- Solid HIPAA privacy/security and PHI handling knowledge
- Experience using AI-assisted tooling (Copilot, Devin, Windsurf) for requirements, test case generation, and spec-driven documentation
- Claims adjudication, pricing, payment, and remittance
- FEP claims processing (FEP Direct/Express, OPM/FEHB rules)
- Benefit administration, accumulators, COB/TPL, overpayment recovery
- Regulatory: HIPAA, ACA, No Surprises Act, CMS mandates
- Facets / QNXT / HealthEdge HealthRules / NASCO / Amisys
- FEP Direct / FEP Express
- Optum CES / ClaimsXten
- X12 5010 (837, 835, 834, 270/271, 276/277, 278), NCPDP
- CMS-1500, UB-04, flat file, XML, JSON, REST APIs
- SQL (Oracle, SQL Server, DB2, PostgreSQL)
- Advanced Excel, data mapping and reconciliation
- Power BI / Tableau; Snowflake (preferred)
- Jira, Azure DevOps, Confluence, Visio, Lucid chart
- QTest / Zephyr / ALM for test and defect management
- Agile, Scrum, SAFe; AI-assisted spec-driven analysis
- Ability to work independently with minimal support
- Follow Best practices while coding
- Ability to work with diverse group of stakeholders and integration teams to complete the work
- 8.00 Years of Experience
- BCBS plan experience, including Inter-Plan/ITS BlueCard host-home claims flows
- Claims platform implementation, conversion, or migration experience
- Provider contract configuration, fee schedules, and repricing logic
- Payment integrity tools (Optum CES, ClaimsXten) and EDI gateways (Edifecs, Availity, TriZetto)
- Medicare Advantage, Medicaid, or ACA/Marketplace claims exposure
- Cloud/data platforms (AWS, Azure, Snowflake) and BI tools (Power BI, Tableau)
- RPA for claims operations (UiPath, Automation Anywhere)
- Certifications: CBAP, PMI-PBA, CSPO/SAFe POPM, AHIP, or AAPC/AHIMA coding credentials
Benefits
- Health Benefits
- Referral Program
- Excellent growth and advancement opportunities
Company Overview
Company H1B Sponsorship