Business Analyst - Utilization Management

Role & responsibilities

Come join our team! Help us tackle the data usability challenge for payers. Your expertise and experience will help drive meaningful performance outcomes. You'll also have the chance to advance your career, acquire new skills, and collaborate with some of the most innovative minds in payer data management.

Business Analyst with Utilization Management and Care Management

You Will Be Responsible for:

Requirements Gathering and Analysis

technical and business requirements, developing and reviewing QA/user acceptance testing criteria, and business systems analysis, including data and gap analyses.

Stakeholder coordination/collaboration

Mock-ups/Prototyping

User Acceptance Testing/QA Process

Partnering with Agile Scrum Teams

Solution Maintenance

Continual Learning

Must-Have Qualifications:

• Deep understanding of how US Health Insurers (payers) utilization management and care management programs clinical and pharmacy, including prior authorization processes, workflows, regulatory compliance, data analysis and interpretation (claims, authorizations, case management), and member engagement
• 5+ years of experience working with US healthcare data (claims, clinical, member, provider, CMS files, etc.) and standards (e.g., HL7, FHIR, EDI, CDA) and integration
• 5+ years of progressive experience in business requirements management (definition, documentation, mock-ups, data analysis)
• 3+ years experience participating in UAT process management – test case planning and scenarios, writing UAT acceptance criteria, UAT test case execution, tracking and resolving defects, and UAT closure
• Proficiency in data mapping and data exchange protocols (e.g., API, JSON, XML) related to health information systems.
• Proficiency in SQL, Python, and/or other programming languages for data extraction and transformation.
• Working knowledge of UM and Care Management systems of record
• Strong communicator who can share domain expertise effectively across multiple departments from Sales, Client Delivery, Product, Engineering, and Information Security
• "Roll up your sleeves mentality" working side-by-side with your team.
• Self-starter with demonstrated ability to drive workstreams independently and manage risks with strong compass on when to escalate issues.
• Demonstrated ability to thrive in a fast-paced, dynamic startup environment.

Nice-to-Have Qualifications:

• Working knowledge of US healthcare (one or more) - health insurance markets, government sponsored health plans (Medicare/Medicaid), and/or care delivery and reimbursement models (e.g. VBC, population health, risk adjustment)
• Familiarity with cloud platforms (e.g., AWS, Azure, Databricks, Snowflake, etc.) for hosting healthcare applications and data storage.
• Experience with EHRs and/or HIEs and healthcare data workflows.
• Experience with healthcare analytics and data visualization tools (e.g., Power BI, Tableau)
• Experience with Agile methodologies in healthcare technology projects.

Interest in Advanced Analytics, Data Science, and/or GenAi

Preferred candidate profile