Senior Systems Analyst – Healthcare Payer

Job Title

Senior Systems Analyst – Healthcare Payer

Job Location

Cary, NC

Rate

$55-$60/hr.

candidate will have hands-on experience with claims, eligibility, member, provider, benefits, prior authorization, and care-management workflows, along with strong knowledge of healthcare interoperability standards, APIs, data mapping, SQL, and system integration.

Required Qualifications

Bachelor’s or master’s degree in Computer Science, Information Systems, Engineering, Healthcare Informatics, or a related discipline.

8+ years of experience as a Systems Analyst, Senior Business Systems Analyst, Technical Business Analyst, or similar role.

At least 3 years of direct Healthcare Payer experience.

Strong understanding of payer business processes, including claims, eligibility, enrollment, benefits, prior authorization, member data, and provider data.

Hands-on experience with requirements gathering, process analysis, system analysis, gap analysis, and impact assessment.

Experience creating BRDs, FRDs, functional specifications, user stories, acceptance criteria, process flows, and data-mapping documents.

Strong knowledge of HL7 FHIR R4 and healthcare API-based interoperability.

Working knowledge of X12 EDI transactions, preferably

837 – Healthcare Claim

835 – Claim Payment/Remittance

834 – Benefit Enrollment

270/271 – Eligibility Inquiry and Response

276/277 – Claim Status Inquiry and Response

278 – Prior Authorization

• Strong SQL skills with experience analyzing healthcare data in relational databases.
• Experience with source-to-target data mapping, data profiling, data validation, and reconciliation.
• Experience analyzing and testing REST APIs using tools such as Postman.
• Working knowledge of JSON, XML, APIs, batch integration, and ETL processes.
• Experience supporting SIT, UAT, defect triage, and production implementation.
• Experience working within Agile/Scrum delivery models using Jira and Confluence.
• Strong written and verbal communication skills with the ability to coordinate across distributed business and technology teams.

Preferred Qualifications

• Experience in vision benefits, dental benefits, managed care, or specialty healthcare insurance.
• Familiarity with provider directories, provider search, member portals, benefit applications, and claims-review platforms.
• Experience supporting CMS interoperability and healthcare data-exchange requirements.
• Exposure to cloud-based healthcare solutions, particularly Microsoft Azure.
• Experience with Azure Data Factory, Snowflake, PostgreSQL, Oracle, or SQL Server.
• Understanding of ETL pipelines, data lakes, microservices, and event-driven integrations.
• Familiarity with Python or PySpark for data analysis and validation.
• Exposure to AI-assisted healthcare workflows, including medical-record summarization, intelligent search, or reviewer-support applications.
• Experience supporting application modernization, legacy-system replacement, or cloud migration.
• Understanding of human-in-the-loop controls for AI-enabled healthcare processes.
• Familiarity with Visio, Git, CI/CD pipelines, and API documentation tools.

Key Responsibilities

Partner with business, operations, product, clinical, and technology stakeholders to gather and analyze functional and non-functional requirements.

Document current-state and future-state processes, business rules, decision points, exceptions, system dependencies, and integration requirements.

Translate business requirements into

Business and functional requirement documents

User stories and acceptance criteria

System and functional specifications

Process flows and use cases

Data dictionaries

Source-to-target mapping documents

Analyze Healthcare Payer workflows involving

Member enrollment and eligibility

Benefit plans and coverage

Claims intake and adjudication

Prior authorization

Provider and network data

Care management

Member and provider servicing

Perform system impact, gap, feasibility, dependency, complexity, and risk assessments for application and process changes.

Analyze healthcare data exchanged through FHIR, HL7, X12 EDI, APIs, batch files, and database interfaces.

Create field-level mappings between internal payer applications, partner systems, APIs, and healthcare data standards.

Work with clinical and billing code sets such as ICD-10, Eligible to work/HCPCS, NDC, SNOMED CT, and LOINC.

Analyze FHIR R4 resources, including Patient, Coverage, Claim, ExplanationOfBenefit, Practitioner, and Organization.

Review REST API specifications and validate JSON/XML request and response payloads, search parameters, business rules, and error handling.

Write SQL queries to investigate member, provider, claims, eligibility, and data-quality issues across systems.

Define data validation rules and identify missing, inconsistent, duplicated, or malformed records.

Collaborate with architects and development teams to convert requirements into appropriate application, API, data-integration, workflow-automation, or rule-based solutions.

Support system integration testing, regression testing, user acceptance testing, and production validation.

Develop test scenarios and test cases, participate in defect triage, and track issues through resolution.

Maintain end-to-end traceability from business requirements through design, development, testing, and production deployment.

Support production issue analysis, root-cause investigation, data reconciliation, and release documentation.

Ensure that system designs and data-processing workflows comply with HIPAA, PHI, PII, role-based access, encryption, and audit requirements.

Participate in Agile ceremonies, including backlog refinement, sprint planning, daily stand-ups, reviews, and retrospectives.

Communicate system impacts, dependencies, risks, and design decisions clearly to technical and non-technical stakeholders.