Health Plan Operations Business Analyst

Position Summary:

We are seeking a detail-oriented and analytical Business Analyst to support our health plan operations with extensive experience in the health insurance payer space.  The ideal candidate will have a strong focus in QNXT system functionality, SQL-based reporting, and IT interface coordination. Position supports day-to-day operations related to data feeds troubleshooting, auditing and validation across various healthcare domains.  This role will bridge the gap between business needs and technical solutions, ensuring data integrity, operational efficiency, and compliance with healthcare regulations. 

Key Responsibilities:

• Monthly, quarterly, and/or annually compiles necessary medical fee schedules and loads them into QNXT adjudication system for provider contracting applications.
• Assures routine vendor files affecting  affecting provider contract, claims, editing and adjudication such as Microdyn, drug price data, third party network updates, service or diagnosis code updates, are scheduled and delivered in a timely manner from Digital Services.
• Validates and audits new file transfers from digital services prior to implementation to assure high accuracy and specifications meet business needs.
• Acts as primary liaison between business users and project teams’ documenting requirement in various management tools ranging from simple spreadsheet to complex applications.
• Participates in quality assurance and user acceptance testing, assisting with report analyst and interpreting results to inform decision making. 
• Provide administrative and operational support to the team and management, contributing to daily operations and project success.
• Analyze and optimize business processes within the QNXT system to support claims, enrollment, provider, and billing operations.
• Develop and maintain complex SQL queries and reports to support operational and regulatory reporting needs.
• Collaborate with IT teams to manage and troubleshoot data interfaces between QNXT and other internal/external systems (e.g., EDI, data warehouses, third-party vendors).   Assure all scheduled electronic files are delivered to business units in a timely manner, performing reconciliation where necessary.
• Translate business requirements into functional specifications for system enhancements and reporting tools.
• Conduct root cause analysis for data discrepancies and operational issues.
• Support testing and validation of system upgrades, patches, and new implementations.
• Document business processes, data flows, and reporting logic.

Qualifications:

• Bachelor’s degree in Business, Information Systems, Healthcare Administration, or related field.
• 3+ years of experience as a Business Analyst in a health plan or managed care environment.
• Strong hands-on experience with QNXT (TriZetto/Cognizant).
• Proficiency in SQL (T-SQL or PL/SQL) for data extraction, transformation, and reporting.
• Familiarity with EDI transactions (e.g., 837, 834, 835) and healthcare data standards.
• Experience working with IT interfaces, data integration, and troubleshooting.
• Excellent analytical, problem-solving, and communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.

Preferred Skills:

• Experience with reporting tools such as SSRS, Power BI, or Tableau.
• Knowledge of healthcare regulations (HIPAA, CMS, NCQA).
• Familiarity with Agile or Scrum methodologies.