Business Systems Analyst lll

Overview

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members.

We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region.

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Brief Summary of purpose:

A Business Systems Analyst III will work on projects that generally involve a complex scope. The BSA III is responsible for analyzing and documenting business requirements, documenting business workflow, developing file mapping and technical specifications, and working with business partners/stakeholders to determine priority of requirements. In addition, assesses system capabilities and interdependencies to define and document business solutions. Works collaboratively with the development team, provides complex technical guidance while applying effective design concepts.

The BSA III proposes or seeks alternative solutions, when necessary, to ensure the proper balance between business and technical needs.

This position requires permanent work authorization in the U.S. We will not provide visa sponsorship or accept candidates on OPT/CPT for this role.

We can only hire from the Following states for this position:

• MA, CT, RI, NH, NY (not Burroughs )

Responsibilities

Primary

Job Responsibilities:

• Provides ongoing business systems analysis and production support for Enrollment, Billing & Provider (EBP) applications and processes, with particular focus on eligibility, enrollment, billing, reconciliation, and outbound vendor file processing.

• Serves as a lead analyst for complex eligibility and vendor file initiatives, including requirements gathering, business rules analysis, file mapping, BRD development and updates, testing coordination, defect resolution, and implementation support.

• Analyzes and documents healthcare EDI and enrollment-related data requirements and mappings, including 834 and 820 transaction processing and associated reconciliation workflows.

• Partners closely with business stakeholders, developers, QA, EDI/Integration teams, and external vendors to translate business needs into technical requirements, resolve data or processing issues, and coordinate testing and implementation activities.

• Supports annual Medicare and other product implementation activities by performing impact assessments, identifying affected applications and files, defining required changes, documenting requirements, and coordinating readiness across impacted units.

• Supports operational reconciliation and process-improvement initiatives, identifying opportunities to automate or standardize file validation, exception handling, monitoring, and business handoffs.

• Demonstrated experience with healthcare enrollment, eligibility, billing, provider data and/or EDI transaction processing strongly preferred. Experience with 834/820 transactions, vendor file interfaces, reconciliation processes, and healthcare payer systems is highly desirable.

Qualifications

Education :

• B…