Senior Business Analyst - Claims Configuration

Summary

As an Senior 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.

Your role in our mission

• 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.
• 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.
• 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.
• 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

• 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.

Preferred Qualifications:

• Strong experience with Medicaid claims processing, claims adjudication, provider reimbursement, benefits, and encounter processing.
• Experience analyzing healthcare transactions (837/835), claims data, and remittance information.
• Proven ability to troubleshoot complex claims issues, identify root causes, and implement effective solutions.
• Experience leading or mentoring analysts and collaborating with clients, stakeholders, and cross-functional teams.
• Knowledge of Agile/SDLC environments and healthcare industry regulations, policies, and compliance requirements.

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.

   

  The deadline to submit applications for this posting is October 30, 2026