JOB Description: Claims BA

The 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 Responsibilities

- Analyse end-to-end claims adjudication workflows, including claim intake, validation, pricing, edits, perks 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 teams
- Domain and Business analysis Skills

- Healthcare, 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 Gathering
- Process Mapping
- Gap Analysis / Root Cause Analysis
- UAT Planning and Execution
- Preferred knowledge different claims processing platforms

📌 “Business Analyst with Claims adjudication (India)
🏢 GK HR Consulting India Private
📍 India