Advisor Business Analyst - Claims Configuration

Gainwell Technologies provides healthcare technology and services that support Medicaid operations and claims processing. The Advisor Business Analyst - Claims Configuration will provide senior functional and technical expertise for Medicaid claims configuration in a Maintenance & Operations environment, lead Configuration Business Analysts, translate requirements into QNXT solutions, and investigate complex claims issues using advanced SQL and relational database analysis.

Responsibilities:

• 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

Requirements:

• 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
• 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
• 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