Lead Business Analyst

Lead Business Systems Analyst – Interoperability & ePA ( electronic Prior Authorization)

Primary Responsibilities

Requirements Leadership

• Own end-to-end business and functional requirements for ePA, CRD, DTR, and PAS.
• Facilitate requirement sessions across business, operations, and technology teams.
• Translate regulatory requirements into business and technical requirements.
• Maintain requirements traceability from CMS regulations through implementation and testing.

Vendor Management

• Act as primary day-to-day requirements lead with Availity.
• Review vendor assumptions, solution designs, workflows, and implementation approaches.
• Track gaps, risks, dependencies, and open decisions.

FHIR & Interoperability Analysis

• Understand CRD, DTR, PAS, Patient Access, Provider Access, and Payer-to-Payer workflows.
• Analyze FHIR resource requirements and data mapping needs.
• Partner with API teams on business workflow impacts.

Cross-Team Coordination

• Coordinate between:
• UM
• Medical Policy
• Clinical Teams
• Horizon API Team
• Availity
• Cognizant
• Prime
• Enterprise Architecture
• Testing

Testing & Readiness

• Define business test scenarios.
• Coordinate end-to-end testing.
• Validate provider workflows.
• Support CMS and BCBSA compliance readiness.

Required Experience

Must Have

• 8+ years as BSA/Product Owner/Product Manager
• Healthcare payer experience
• Prior Authorization experience
• Vendor management experience
• API integration experience
• Strong facilitation and stakeholder management skills

Highly Preferred

• FHIR
• CMS-0057-F
• CRD/DTR/PAS
• HL7
• Interoperability programs
• Utilization Management workflows
• Medical Policy systems