Claim Business Analyst

Level – Team LeadExperience – 7 Years – 10 YearsSkill – Business Analyst (Claims – US Healthcare)Work Location – Coimbatore / Kochi / PuneMode - Work from Office (US Shift)CTC – 10 LPA including 36k variable payJOB Description: Claims BAThe Business Analyst (Claims Adjudication) responsible for analyzing, documenting, and optimizing claims adjudication processes to ensure accurate, timely, and compliant claim payments, acts as a bridge between business stakeholders, claims operations teams, clients, and technology teams to drive system enhancements, process improvements, and regulatory compliance.Key ResponsibilitiesAnalyse end-to-end claims adjudication workflows, including claim intake, validation, pricing, edits, benefits application, payment, and denial processes.Gather and document business requirements for claims processing system enhancements.Translate business needs into functional specifications, user stories, and process flows.Evaluate claim processing rules, benefit plans, fee schedules, provider contracts, and reimbursement methodologies.Support implementation of new claim edits, policies, and regulatory changes.Identify operational gaps and recommend automation opportunities.Perform root cause analysis for claim payment issues, pended claims, and adjudication defects.Analyze denial trends, provider disputes, and payment accuracy metrics.Improve turnaround time (TAT), first-pass auto-adjudication rates, and operational efficiency.Collaborate with Claims Operations, Configuration, Provider Network, Compliance, and IT teams.Facilitate requirement workshops and stakeholder meetings.Provide business support during project implementation and production deployments.Develop test scenarios and test cases.Execute and support User Acceptance Testing (UAT).Validate claims adjudication outcomes against business requirements.Track defects and coordinate resolution with development teamsDomain and Business analysis SkillsHealthcare, Dental, Medicare, Medicaid, or Commercial Claims Processing.Claims lifecycle management.Claims adjudication rules and payment methodologies.Provider contracts and fee schedules.Benefits, eligibility, COB, and authorization processes.Medical coding (ICD-10, CPT, HCPCS) and/or Dental Coding (CDT Codes)Requirement GatheringProcess MappingGap Analysis / Root Cause AnalysisUAT Planning and ExecutionPreferred knowledge different claims processing platformsQualificationBachelor's Degree in Business, Healthcare Administration, Information Systems, or related field.4-10 years of experience in healthcare or Medical / dental claims processing/business analysis.Strong understanding of claims adjudication systems and payer operations.Preferred with BA Role Experience