Healthcare Claims Business Analyst

Healthcare Claims Business Analyst / Subject Matter Expert (BA/SME)

InfoMC is a fast-paced, healthcare technology company delivering integrated care management and population health solutions to health plans and provider organizations. Our person-centered, “whole-person care” and provider approach addresses the behavioral, physical, and social drivers that impact a member’s health and enhances the interaction between plan, enrollee, and provider. Our solutions are designed to help our customers improve quality, reduce costs, and optimize health outcomes for their population.

At InfoMC, we are extraordinarily proud of the company we’re building not to mention our continuous efforts to create a Best Place to Work culture. Our people are InfoMC’s biggest competitive advantage and we’ll continue to invest in our team and people-first culture.

The Healthcare Claims Business Analyst / Subject Matter Expert (BA/SME) serves as InfoMC’s primary domain authority for healthcare claims operations during new client onboarding engagements on the Incedo claims platform. This individual bridges the gap between client operational workflows and the technical capabilities of the Incedo solution, ensuring that each implementation is aligned with payer-side business requirements, regulatory obligations, and industry standards for electronic data interchange (EDI).

The BA/SME works directly with health plan and managed care organization clients to define requirements, configure workflows, validate transaction sets, and guide teams through end-to-end claims lifecycle processes—from member eligibility through remittance and adjudication. The ideal candidate brings deep payer-side experience with HIPAA-mandated EDI transactions, CMS reporting requirements, and the operational realities of claims processing within Medicare Advantage, Medicaid, and commercial health plan environments.

Claims Domain Expertise & Client Advisory

• Serve as the internal and client-facing subject matter expert on healthcare claims operations, EDI transaction standards, and payer-side adjudication logic throughout the Incedo onboarding lifecycle.
• Translate client payer workflows and claims processing requirements into detailed business and functional specifications for the Incedo implementation team.
• Advise clients on best practices for configuring claims intake, adjudication rules, coordination of benefits (COB), appeals and grievance workflows, and remittance processing within Incedo.
• Identify gaps between client legacy processes and Incedo capabilities; document and elevate to product/engineering as applicable.

EDI Transaction Set Knowledge & Validation

The BA/SME must possess hands‑on functional knowledge of the following HIPAA‑mandated ASC X12 transaction sets and their application in a payer environment:

• 834 – Benefit Enrollment and Maintenance: member eligibility file intake from CMS, employer groups, or TPAs; validation of enrollment spans, plan codes, and subscriber/dependent relationships.
• 270 / 271 – Eligibility Inquiry and Response: real‑time and batch eligibility verification, configuration of response logic and benefit information, and integration with member enrollment systems.
• 837P / 837I – Professional and Institutional Claims: inbound claims intake, loop and segment validation, NPI/taxonomy routing, and coordination with Incedo adjudication engine.
• 835 – Healthcare Claim Payment/Advice (ERA): remittance generation, CAS segment coding, ERA reconciliation against adjudicated claims, and ERA/EFT pairing.
• 276 / 277 – Claim Status Request and Response: outbound claims status inquiry workflows, 277CA acknowledgment processing, and payer‑to‑provider communication configuration.
• 278 – Health Care Services Review (Prior Authorization): inbound and outbound PA request/response workflows, integration with Incedo utilization management module, and CMS‑0057‑F electronic PA compliance.
• 275 – Patient Information (Additional Information to Support a Health Care Claim): receipt and routing of clinical attachments and supporting documentation submitted by providers in conjunction with claims, including coordination with Incedo adjudication…