Advisor Business Analyst - Claims Configuration

Summary

As an Advisor Business Analyst - Claims Configuration at Gainwell, you will provide senior functional and technical expertise for Medicaid claims configuration within a Maintenance & Operations environment. You will translate client requirements, Medicaid policy, operational needs, and claims-processing outcomes into scalable QNXT configuration solutions while leading a team of Configuration Business Analysts.

This role requires deep hands-on QNXT configuration expertise, advanced SQL and relational database knowledge, and the ability to independently investigate complex claims issues, identify root cause, determine corrective solutions, and clearly communicate recommendations to clients, vendors, and internal cross-functional teams.

Your role in our mission

Claims Configuration Leadership

• Lead, mentor, and provide day-to-day technical direction to a team of Claims Configuration Business Analysts.
• Serve as the senior configuration subject matter expert and trusted advisor for assigned CEF Claims M&O accounts.
• Review configuration analysis, solution designs, implementation plans, and validation results for quality, accuracy, and downstream impact.
• Establish consistent configuration practices, documentation standards, peer-review controls, and knowledge-transfer processes.

Client and Cross-Functional Engagement

• Interact directly with clients, vendors, and internal business, product, development, testing, operations, finance, provider, member, and encounter teams.
• Lead requirements discussions, configuration reviews, issue-resolution sessions, defect triage, solution walkthroughs, and operational governance discussions.
• Translate complex technical findings into clear business impacts, options, risks, and recommendations for stakeholders and leadership.
• Own assigned issues and enhancements from intake and analysis through implementation, validation, communication, and closure.

Configuration Analysis and Solution Design

• Configure and support QNXT claims solutions across contracts, benefits, fee schedules, payment methodologies, capitation, business rules, claims adjudication logic, X12 transaction data requirements, and CARC/RARC processing.
• Translate Medicaid policy, contractual requirements, and operational needs into configuration specifications, business rules, design artifacts, and acceptance criteria.
• Assess the full impact of proposed changes across claims adjudication, pricing, benefits, provider reimbursement, encounters, remittance, financial processing, reporting, and downstream integrations.
• Determine whether an issue is caused by configuration, data, policy interpretation, user processing, interface behavior, product functionality, or another upstream or downstream dependency.

Data Analysis, Root Cause Analysis, and Production Support

• Write and execute complex SQL queries to analyze claims, claim lines, provider affiliations, contracts, benefits, pricing, member eligibility, edits, accumulators, encounters, and financial data.
• Use relational database schemas and data relationships to trace system behavior and validate claims-processing outcomes.
• Perform claim-level and population-level root cause analysis for denials, pends, unexpected edits, underpayments, overpayments, duplicate conditions, encounter rejections, and other processing anomalies.
• Quantify impacted claims and populations, document evidence, compare expected and actual results, and recommend sustainable corrective actions.
• Support production incidents, client inquiries, audit requests, configuration defects, data fixes, and ad hoc reporting needs.
• Validate configuration changes through targeted data analysis, claims testing, regression review, and post-implementation monitoring.

What we're looking for

Top 3 Required Skills:

• 9+ years of hands-on, highly proficient QNXT configuration experience, with demonstrated depth in contracts, benefits, fee schedules and multiple payment methodologies, capitation, rules, successful data points for X12 transactions, and CARC/RARC processing.
• Thorough understanding of relational database concepts, healthcare data models, schemas, keys, and data relationships.
• Demonstrated competency writing complex SQL queries for claims analysis, validation, troubleshooting, root cause analysis, and reporting.

Additional preferred skills:

• Strong knowledge of Medicaid claims processing, claims adjudication, provider reimbursement, benefit administration, edits, pricing, and encounter processing.
• Experience analyzing X12 healthcare transactions, including 837 and 835 transaction data and associated remittance adjustment reason codes.
• Proven ability to independently analyze complex claim scenarios, identify root cause, assess impact, and develop actionable business and configuration solutions.
• Experience leading or mentoring Configuration Business Analysts and reviewing technical or functional work products.
• Strong client-facing communication, facilitation, presentation, documentation, and stakeholder-management skills.
• Experience working within SDLC, Agile delivery, testing, release management, and production-support environments.
• Bachelor’s degree in Computer Science, Information Systems, Health Informatics, Business Administration, or a related field, or an equivalent combination of education and relevant experience.

What sets you apart

• Experience supporting Medicaid claims configuration in a multi-account CEF Maintenance & Operations environment.
• Deep expertise in provider contracts, fee schedules, alternative payment methodologies, capitation, benefits, edits, and claims rules.
• Experience with operational monitoring, trend analysis, claims inventory analysis, first-pass outcomes, denials, and reprocessing impacts.
• Knowledge of CMS guidance, state Medicaid policy, MITA, encounter processing, financial reconciliation, and compliance considerations.
• Experience with IT service management and work-tracking tools such as ServiceNow, Jira, or similar platforms.
• Ability to balance client priorities, production risk, operational urgency, and long-term configuration sustainability

What you should expect in this role

• Fully remote options from most U.S. locations and territories.
• Video cameras must be used during all interviews and during the initial week of orientation.
• Work may include production support, priority issue resolution, scheduled releases, and coordination across multiple client and internal teams.
• This job description may be refined to align with approved requisition, job profile, location, compensation, and Talent Acquisition requirements.

• The deadline to submit applications for this posting is September 24, 2026

Please ensure you join all screenings, interviews and meetings from a quiet location with a stable internet connection. 

Video is required for screenings and interviews, so please test your camera and microphone in advance.

Do not use AI tools, virtual backgrounds/filters, or visual enhancements during the interview.

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