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Business Analyst – Provider Networks & Care Management

Experience: 6–10+ years (flexible based on scope)
Domain: Healthcare / Managed Care / Payer Operations

Role Overview

We are seeking an experienced Business Analyst (BA) with strong expertise in Provider Network management and Care Management programs. This role partners with clinical, network, operations, IT, and analytics teams to analyze business processes, define requirements, and support initiatives that improve clinical outcomes, operational efficiency, cost management, and regulatory compliance.

The ideal candidate has deep knowledge of healthcare payer operations, understands end‑to‑end care management workflows, and can translate business needs into clear functional and technical requirements.

Note: This position is not eligible for Immigration Sponsorship at this time

Key Responsibilities

Provider Network Analysis

• Analyze provider network operations including contracting, credentialing, directory management, network adequacy, and access standards.

• Support initiatives related to network optimization, provider performance, and value‑based care arrangements.

• Gather and document requirements for provider data management, directory accuracy, and compliance reporting.

• Act as a liaison between business users and technical teams for provider network systems.

Care Management & Clinical Programs

• Analyze Care Management workflows, including utilization management, case management, disease management, and population health programs.

• Support process improvements around prior authorization, referrals, transitions of care, and closure of care gaps.

• Translate clinical and operational needs into clear business and system requirements.

• Assist in the measurement and reporting of care outcomes, quality metrics, and utilization trends.

Business & Systems Analysis

• Conduct stakeholder interviews, workshops, and current‑state/future‑state process analysis.

• Develop Business Requirement Documents (BRDs), Functional Requirement Documents (FRDs), process flows, and user stories.

• Support system enhancements, integrations, and data initiatives related to provider and care management platforms.

• Validate solutions through UAT planning, execution, and defect triage.

Data, Reporting & Compliance

• Analyze healthcare data related to cost, utilization, quality, risk stratification, and provider performance.

• Support reporting for regulatory and accreditation requirements (e.g., CMS, NCQA, state mandates).

• Ensure alignment with healthcare standards such as ICD‑10, CPT, HCPCS, HEDIS, and FHIR where applicable.

Required Qualifications

Experience

• 6–10+ years of experience as a Business Analyst in healthcare.

• Strong hands‑on experience with Provider Network operations and Care Management programs.

• Experience working with payer systems or healthcare platforms supporting network and care management functions.

Domain Knowledge

• Provider contracting, credentialing, and directory management.

• Care Management, Utilization Management, Case/Disease Management models.

• Value‑Based Care, ACOs, and quality improvement initiatives.

• Understanding of payer workflows and end‑to‑end member/provider lifecycle.

Technical & Functional Skills

• Requirements elicitation and documentation (BRD, FRD, user stories).

• Process modeling tools (Visio, Lucidchart, BPMN).

• Agile and/or Waterfall delivery methodologies.

• Data analysis using SQL, Excel, or BI tools (reported or self‑service).

• Familiarity with healthcare platforms such as care management systems, provider data systems, and claims platforms.

Soft Skills

• Strong communication skills with clinical, business, and technical stakeholders.

• Ability to translate complex clinical and operational concepts into actionable requirements.

• Analytical mindset with strong problem‑solving capabilities.

• Proven ability to manage multiple priorities in a fast‑paced environment.

Nice‑to‑Have

• Experience supporting