Job Details

Title: HRP Business Analyst
Client: Health Insurance
Location: Philadelphia PA, (mostly remote)
Type: Contract to hire

Overview

The HRP Business Analyst is responsible for ensuring the accurate configuration and enforcement of medical and claim payment policies in accordance with business requirements. This role analyzes claims data and trends to determine appropriate system enforcement, identifies opportunities for improvement, and supports policy accuracy through collaboration, testing, and quality assurance.

Key Responsibilities

• Provide day-to-day oversight of assigned work and collaborate with peers to improve business processes and operational efficiency
• Develop policy enforcement requirements aligned with medical and claim payment policy criteria, including claim system edits, prior authorization, desk-level procedures, and post-payment review
• Partner with internal stakeholders to understand policy criteria and medical coding rules and assess system capabilities
• Collaborate with cross-functional teams and external vendors to ensure accurate policy implementation based on business requirements
• Identify policies requiring manual review when systematic enforcement is not feasible or recommended
• Document and escalate system-level issues in a timely manner, including execution of corrective action plans when applicable
• Perform quality assurance through development and review of claims data utilization reports to confirm proper policy enforcement
• Review and resolve claims incidents related to policy configuration issues, ensuring all impacted claims are identified, adjusted, and reported
• Conduct root cause analysis to identify sources of policy set-up issues
• Participate in User Acceptance Testing in collaboration with external vendors
• Provide input to regulatory and oversight teams to ensure compliance with applicable requirements, including CMS, BlueCard processing rules, product rules, denial messaging, and member or provider liability
• Interact effectively with associates and leadership at all levels, as well as external consultants, vendors, and partners
• Perform additional related duties as assigned

• Bachelor's degree in a relevant discipline or equivalent work experience
• Minimum of five years of experience in Claims, Operations, or Business Requirements Development
• Ability to work independently, manage priorities, meet deadlines, and assess issue criticality
• Strong problem-solving skills with exceptional attention to detail
• Effective written and verbal communication skills
• Proficiency with business tools including Microsoft Excel, Word, PowerPoint, SharePoint, and Teams
• Working knowledge of organizational operations, business processes, and the end-to-end claims lifecycle

• Coding certification such as CCS, CPC, RHIA, or RHIT
• Working knowledge of HealthRules Payer and Source claims processing systems
• Demonstrated time management skills, including the ability to prioritize deliverables and communicate realistic resolution timelines