Healthcare BA with Medicaid, insurance, payer, modeling, enrollment, claims, rules and laws/regulations/policy mining experience

Request ID: EPC-8318-1 (98890831)

Healthcare BA with Medicaid, insurance, payer, modeling, enrollment, claims, rules and laws/regulations/policy mining experience

Location: Columbia, SC
Duration: 12 Months
Remote: 25%

REQUIRED SKILLS (RANK IN ORDER OF IMPORTANCE):

• 8+ years’ experience in government IT projects as a business analyst or related duties
• 6+ years’ experience eliciting, mining, and documenting business rules
• General Subject Matter Expertise as it relates to Medicaid or other healthcare insurance experience (project or operations)
• Firm understanding of health care payer business process
• Strong understanding of business modeling techniques
• Integrated healthcare delivery from member enrollment though to claims payment
• Business operations experience in member enrollment though to claims payment
• Ability to effectively communicate to executive management, line management, project management, and team members.
• Experience and ability to obtain business rules and requirements information by interviewing business personnel and by mining laws, regulations, and policy documents.
• Superb written and oral communications skills, including the ability to write requirements and Use Cases. Very Strong proficiency in English is required

REQUIRED EDUCATION:
Bachelor’s degree in a technical, business, or healthcare field.

• This position requires an individual with strong analytical skills and experience in:
– Claims Processing in a large health care payer environment
– Provider Enrollment and Management
– Member Eligibility and related functions

OBJECTIVES TO BE FULFILLED BY CANDIDATE:
The principal duties of this position are to develop and maintain business requirements with associated artifacts such as requirements plans, process flows, and other models as needed.

Daily work will concentrate on these work streams:
• Member
• Provider
• Claims
• Prior Authorization
• Finance
These work streams will support the following modules for RMMIS:
• Business Intelligence System
• Administrative Services Organization (ASO) for Fee for Service (FFS) claims
• Pharmacy Benefits Administrator (PBA)
• Dental Administrative Services Organization (DASO)
• Accounting and Finance
• Third Party Liability (TPL)
• System Integration and Operations (SIOPS)
• Technology Framework (Integration Hub, Portal and Enterprise Data Services)
• RMMIS Program Management
Specific duties include, but are not limited to:
• Plan, elicit, capture, analyze and validate business, functional and technical requirements.
• Facilitate requirements elicitation sessions and walkthroughs with business and IT resources.
• Collaborate with departments to identify, document and communicate business needs and provide solutions.
• Develop business rules via interviews, translation of governing documents and other means.
• Conduct JAD Sessions with Product Owners
• Partner with business owners on requirements development and project collaboration
• Assist other team members in performing business rules, requirements, and modeling duties.
• Research business rules, requirements, and models.
• Use case development
• Requirements traceability

Experience
Administrative Verbal Communication Skills Yes 1 Expert Currently Using 6 + Years
Administrative Written Communication Skills Yes 1 Expert Currently Using 6 + Years
Education BA Degree- Technical, Business, or Healthcare field Yes 1 Expert Currently Using 4 – 6 Years
Miscellaneous business modeling techniques Yes 1 Expert Currently Using 6 + Years
Miscellaneous experience in government IT projects as a business analyst or related duties Yes 1 Expert Currently Using 6 + Years
MMIS – Medicaid Management Informaiton System Medicaid Yes 1 Expert Currently Using 6 + Years
Program Management – RUP methodology Eliciting, mining, and documenting business rules, processes Yes 1 Expert Currently Using 6 + Years

Additional Skills:
• Firm understanding of health care payer business process.
• Integrated healthcare delivery from member enrollment though to claims payment.
• Business operations experience in member enrollment though to claims payment.
• Ability to effectively communicate to executive management, line management, project management, and team members.
• Experience and ability to obtain business rules and requirements information by interviewing business personnel and by mining laws, regulations, and policy documents.

Remote Work Availability: 25%

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