Healthcare Claims & Prior Authorization Analyst (Remote)

Tier4 Group; Quincy (MA); Hybrid; USD 85,000 - 115,000; Full time

Job summary

Tier4 Group is seeking an experienced Business Analyst focused on Prior Authorization and claims operations. This role supports provider reimbursement, referrals, and related workflows within a healthcare technology environment, collaborating with stakeholders, tech teams, and vendors on system enhancements.

The ideal candidate understands healthcare operations, SDLC, and payer systems. Experience with Medicaid or managed care is preferred, and the position offers a largely remote arrangement

Qualifications

• Bachelor's degree in Business, Information Technology, Healthcare Administration, or related field.
• 3+ years of Business Analyst experience within healthcare environments.
• Strong knowledge of Prior Authorization, claims processing, referrals, and healthcare reimbursement processes.
• Experience gathering business requirements and supporting full SDLC projects.
• Understanding of Agile and/or traditional project methodologies.
• Strong analytical and problem-solving skills.
• Experience with data analysis and SQL queries.
• Excellent written and verbal communication skills.

Responsibilities

• Lead and participate in requirements gathering sessions, stakeholder interviews, and solution design workshops.
• Analyze and document business, functional, and system requirements for claims processing, prior authorization, referral management, and reimbursement initiatives.
• Conduct gap analysis and recommend process improvements to enhance operational efficiency and compliance.
• Collaborate with development, quality assurance, and business teams throughout the project lifecycle.
• Develop test strategies, test scenarios, and test cases based on documented requirements.
• Execute testing activities, validate results, and support user acceptance testing (UAT).
• Assist with release planning, implementation activities, and post-production stabilization efforts.
• Monitor system issues, support root cause analysis, and help develop corrective action plans.
• Partner with vendors and internal stakeholders to ensure solutions meet business requirements.
• Communicate project updates, system changes, and impacts to key stakeholders.
• Provide operational support and subject matter expertise related to claims, prior authorization, and referral workflows.
• Perform data analysis and reporting, including querying data to support business decisions and issue resolution.
• Create and maintain process documentation, training materials, and user guides.

Skills

Business Analysis

Prior Authorization

SQL Queries

SDLC

Agile Methodologies

Documentation

Education

Bachelor's degree in Business/IT/Healthcare

Job description

Tier4 Group is seeking an experienced Business Analyst focused on Prior Authorization and claims operations. This role supports provider reimbursement, referrals, and related workflows within a healthcare technology environment, collaborating with stakeholders, tech teams, and vendors on system enhancements.

The ideal candidate understands healthcare operations, SDLC, and payer systems. Experience with Medicaid or managed care is preferred, and the position offers a largely remote arrangement