Location: USA Remote
Employment Type: Full-Time / Contract
Visa Requirement: Visa Independent Candidates Only
We are seeking a highly experienced Senior Healthcare Business Analyst / Behavioral Health SME with strong expertise in Healthcare Payer operations and Behavioral Health . The ideal candidate will have deep knowledge of Behavioral Health processes, payer operations, healthcare regulations, business analysis, and healthcare technology platforms.
The candidate should be able to effectively bridge business and technology teams and drive requirements, process improvements, system solutions, and transformation initiatives.
Required Qualifications10+ years of experience in Healthcare Payer environments.
5+ years of hands-on experience in Behavioral Health , including Mental Health and Substance Use Disorders (SUD).
Strong understanding of the end-to-end healthcare payer lifecycle, including:
Eligibility & Enrollment
Benefits Configuration
Claims Processing & Adjudication
Prior Authorization
Care & Case Management
Provider Management
Appeals & Grievances
Payment Integrity
Strong knowledge of Behavioral Health regulations and compliance requirements, including:
MHPAEA (Mental Health Parity and Addiction Equity Act)
Medicare & Medicaid Behavioral Health programs
HIPAA
CMS regulations
State-specific healthcare requirements
NCQA / URAC standards
Requirements gathering and analysis
Business Requirements Documents (BRD)
Functional Requirements Documents (FRD)
User Stories and Acceptance Criteria
Process Mapping
Gap Analysis
Business Process Improvement
UAT / SIT support
Defect management
Stakeholder management
Business and technical solution discussions
Experience with one or more of the following platforms is highly preferred:
Facets
QNXT
HealthRules
GuidingCare
TruCare
Similar healthcare payer platforms
Strong understanding of healthcare transactions and interoperability standards, including:
837 Claims
835 Electronic Remittance Advice
834 Enrollment
270/271 Eligibility
HL7
FHIR
Strong SQL skills
Data analysis
Healthcare data mapping
System integration
Data validation and reconciliation
Understanding of healthcare interfaces and integrations
Commercial, Medicare, and Medicaid lines of business
Behavioral Health Care Management
Utilization Management
Value-Based Care programs
Healthcare payer modernization
Data transformation initiatives
AI / Digital Transformation initiatives
Experience working with cross-functional business, technology, product, and vendor teams
The ideal candidate will combine strong Behavioral Health payer SME expertise with senior-level Business Analysis capabilities and healthcare technology knowledge.
The candidate should have demonstrated experience across:
Behavioral Health + Claims + Eligibility + Benefits + Care Management + Provider Operations + Regulatory Compliance + Payer Technology Platforms
The successful candidate should be comfortable leading strategic business discussions as well as detailed system and solution-design discussions with business and technical stakeholders.
Additional RequirementsMust be authorized to work in the United States without sponsorship.
Must be available to work remotely.
Strong communication and stakeholder management skills.
Ability to work independently and collaboratively in an Agile environment.
Candidates should be available for interviews on short notice.
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