Position Summary

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.

What the Healthcare Claims BA/SME Does:

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 escalate to product/engineering as applicable

•Support clients in designing claims data migration strategies, including crosswalks from legacy systems and validation of historical claims data integrity

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 workflows requiring medical records or authorization documentation

•999 / TA1 – Functional Acknowledgment and Interchange Acknowledgment: EDI gateway configuration, acknowledgment tracking, and error-handling workflows

Onboarding & Implementation Execution

•Lead business analysis workstreams during new client onboarding, including requirements discovery sessions, workflow mapping, and gap analysis documentation

•Develop and maintain detailed business requirements documents (BRDs), functional specifications, data mapping templates, and EDI companion guides customized to each client’s trading partner environment

•Coordinate with the client’s EDI team and clearinghouse partners to complete end-to-end transaction testing for all applicable X12 transaction sets

•Facilitate and support user acceptance testing (UAT) for claims processing scenarios, ensuring adjudication outcomes align with client benefit plan configuration and state/federal requirements

•Document client-specific configurations, workflow decisions, and known edge cases in InfoMC’s implementation knowledge base

•Partner with Engagement Managers and Technical Leads to ensure claims-related milestones are on track, risks are escalated promptly, and client expectations are managed

Regulatory & Compliance Alignment

•Maintain current knowledge of CMS regulations, HIPAA transaction and code set standards (45 CFR Part 162), and state Medicaid agency requirements as they affect claims operations

•Advise clients on compliance with CMS-0057-F (electronic prior authorization), No Surprises Act (NSA) claims adjudication timelines, and applicable state prompt pay laws

•Support clients in Medicare Advantage (Part C), Medicaid managed care, and CHIP programs in configuring Incedo to meet CMS encounter data submission requirements

•Monitor and communicate updates to X12 transaction standards, ICD/CPT/HCPCS code set releases, and CMS NCCI edits that may affect client configurations

Knowledge Sharing & Continuous Improvement

•Develop and maintain internal training materials, job aids, and onboarding playbooks related to claims operations and EDI workflows on the Incedo platform

•Mentor junior implementation staff on payer claims concepts, EDI troubleshooting, and client-facing discovery techniques

•Collaborate with InfoMC’s Product and Engineering teams to communicate client-driven enhancement requests and emerging market requirements

•Contribute to the ongoing refinement of InfoMC’s Implementation Playbook with claims-specific best practices and lessons learned

What the Healthcare Claims BA/SME Demonstrates:

•Deep command of the end-to-end claims lifecycle from the payer’s perspective: member eligibility, claims intake, adjudication, COB, appeals, and remittance

•Functional mastery of HIPAA ASC X12 transaction sets (834, 837P/I/D, 835, 270/271, 276/277, 278, 999/TA1) with the ability to read, interpret, and troubleshoot raw EDI files

•Ability to conduct structured discovery sessions with health plan operations teams, extract requirements, and translate them into actionable technical specifications

•Strong written communication skills, including the ability to produce clear BRDs, data dictionaries, and process flow diagrams

•Comfort operating in a client-facing role across multiple concurrent engagements, managing competing priorities with minimal supervision

•Collaborative mindset with the ability to coordinate across internal teams (Implementation, Product, Engineering, QA) and external stakeholders (client IT, clearinghouses, trading partners)

•Analytical rigor and attention to detail when validating EDI transaction data, reviewing adjudication outcomes, and auditing benefit plan configurations

•Working knowledge of relational databases and SQL sufficient to support data validation and claims reporting tasks

Qualifications

Required

•Bachelor’s Degree in Health Information Management, Healthcare Administration, Computer Science, Business, or equivalent work experience

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