Claims Business Analyst

Claims Business Analyst - Health Insurance Location: Philadelphia, PA (Hybrid – onsite Tuesday, Wednesday, Thursday) We are seeking a Claims Business Analyst to support the development, implementation, and oversight of medical and claim payment policy enforcement within a healthcare payer environment. This role will partner cross-functionally with internal stakeholders and external vendors to ensure policies are accurately configured and enforced within claims systems. The ideal candidate will have strong experience within claims operations, business analysis, policy implementation, and healthcare reimbursement workflows. Key Responsibilities: • Develop and maintain policy enforcement requirements for medical and claim payment policies • Analyze claims data and trends to identify enforcement gaps, inconsistencies, and process improvement opportunities • Partner with internal teams to understand medical coding rules, policy criteria, and system capabilities • Support implementation efforts with external vendors and internal operational teams • Conduct root cause analysis related to claims incidents and policy setup issues • Review claims utilization and enforcement reporting to ensure policy accuracy and compliance • Perform User Acceptance Testing (UAT) for system and policy changes • Provide input related to CMS guidelines, BlueCard processing, denial messaging, and provider/member liability • Identify opportunities for manual review workflows when automated enforcement is not appropriate • Assist with escalation procedures, corrective action plans, and operational documentation Qualifications: • Bachelor’s degree or equivalent experience • 5+ years of experience within healthcare claims, payer operations, business analysis, or business requirements development • Strong understanding of the end-to-end claims lifecycle • Experience working with claims systems, policy implementation, and operational workflows • Knowledge of medical coding and reimbursement methodologies preferred • Coding certifications such as CPC, CCS, RHIA, or RHIT preferred • Strong analytical, organizational, and communication skills • Proficiency with Excel, Word, PowerPoint, SharePoint, and Teams This is an excellent opportunity for someone with payer-side healthcare operations experience who enjoys solving complex operational and claims issues in a highly collaborative environment.