Senior Healthcare Business Analyst - Provider Networks & Care Management

Business Analyst - Provider Networks & Care Management

Client: Fractal

Location: Remote (U.S.)

Employment Type: Full-Time

Salary: Up to $195,000 (Based on experience and location)

Visa Sponsorship: Not available for this role

About Fractal

Fractal is a global AI and analytics company that partners with Fortune 500 organizations to solve complex business challenges using Artificial Intelligence, advanced analytics, and digital transformation. Fractal combines deep domain expertise with cutting-edge technology to improve decision-making across industries, including healthcare, financial services, consumer goods, and life sciences.

Position Overview

Fractal is seeking an experienced Business Analyst specializing in Provider Networks and Care Management within the healthcare payer domain. This role will work closely with clinical teams, provider operations, business stakeholders, product owners, architects, developers, and analytics teams to analyze healthcare business processes, gather requirements, improve operational workflows, and support digital transformation initiatives.

The ideal candidate possesses extensive knowledge of healthcare payer operations, provider network management, care management programs, healthcare regulations, and system implementation projects. They should be capable of translating complex business needs into detailed functional requirements that enable successful software delivery and operational improvements.

Key Responsibilities

Provider Network Management

• Analyze end-to-end provider lifecycle processes including:
• Provider onboarding
• Credentialing
• Recredentialing
• Provider contracting
• Network adequacy
• Directory management
• Provider maintenance
• Provider data quality
• Gather and document business requirements for:
• Provider data management
• Network optimization
• Provider performance measurement
• Directory accuracy
• Regulatory compliance
• Collaborate with provider operations, compliance, and IT teams to enhance provider network systems.
• Support Value-Based Care (VBC) initiatives and provider performance programs.
• Identify opportunities to improve provider onboarding efficiency and operational workflows.
  
  

Care Management & Clinical Operations

Analyze and improve workflows across:

• Care Management
• Case Management
• Disease Management
• Utilization Management
• Population Health
• Prior Authorization
• Referrals
• Transition of Care
• Care Gap Closure
• Chronic Disease Programs
  
  

Responsibilities include:

• Gathering clinical and operational requirements
• Defining workflow improvements
• Supporting automation initiatives
• Improving member engagement processes
• Supporting quality improvement initiatives
• Enhancing care coordination
  
  

Business Analysis

• Conduct stakeholder interviews
• Facilitate workshops
• Perform current-state and future-state process analysis
• Create:
• Business Requirement Documents (BRD)
• Functional Requirement Documents (FRD)
• User Stories
• Use Cases
• Acceptance Criteria
• Process Flow Diagrams
• BPMN Models
• Data Mapping Documents
• Gap Analysis
• Work with Product Owners and Development teams throughout Agile delivery.
  
  

System Implementation

Support healthcare technology initiatives involving:

• Provider Data Platforms
• Care Management Systems
• Claims Systems
• Member Systems
• Authorization Platforms
• CRM Solutions
• Interoperability Platforms
  
  

Responsibilities include:

• Requirement validation
• Functional design reviews
• Data mapping
• Integration support
• Sprint planning
• Backlog refinement

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• User Acceptance Testing (UAT)
• Defect management
• Production support
  
  

Data Analysis & Reporting

Analyze healthcare data including:

• Claims
• Utilization
• Provider Performance
• Member Outcomes
• Risk Scores
• Cost of Care
• Care Gap Metrics
• Network Performance
• Quality Metrics
  
  

Use:

• SQL
• Excel
• BI tools
• Dashboards
• Reporting Platforms
  
  

Generate reports supporting:

• Operational KPIs
• Clinical outcomes
• Executive dashboards
• Compliance reporting
  
  

Regulatory & Compliance

Support compliance initiatives involving:

• CMS
• NCQA
• State Medicaid
• Commercial Payers
• HIPAA
  
  

Knowledge of:

• HEDIS
• STAR Ratings
• Risk Adjustment
• ICD-10
• CPT
• HCPCS
• FHIR
• HL7
  
  

Ensure business processes comply with regulatory standards and accreditation requirements.

Required Qualifications

• Bachelor's degree in Business, Healthcare Administration, Information Systems, Computer Science, or related field.
• 6-10+ years of Business Analyst experience.
• Minimum 5+ years within Healthcare Payer domain.
• Strong experience in:
• Provider Network Management
• Care Management
• Provider Operations
• Healthcare Claims
• Utilization Management
• Case Management
• Experience working directly with healthcare business stakeholders.
• Excellent analytical and documentation skills.
  
  

Required Healthcare Domain Experience

Strong understanding of:

Provider Operations

• Provider Contracting
• Credentialing
• Recredentialing
• Provider Directory
• Provider Data Management
• Network Adequacy
• Provider Performance
  
  

Care Management

• Case Management
• Disease Management
• Utilization Management
• Prior Authorization
• Care Coordination
• Population Health
• Chronic Care Programs
  
  

Healthcare Payer

• Claims Processing
• Member Enrollment
• Eligibility

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• Benefits
• Provider Lifecycle
• Cost Management
• Medical Management
  
  

Technical Skills

• Business Requirement Documentation
• Functional Requirement Documentation
• Agile Scrum
• Waterfall
• Jira
• Confluence
• SQL
• Excel
• Visio
• Lucidchart
• BPMN
• Data Mapping
• UAT Planning
• Test Case Preparation
• Defect Tracking
  
  

Healthcare Knowledge

Experience with:

• CMS Regulations
• NCQA
• HEDIS
• STAR Ratings
• Risk Adjustment
• ICD-10
• CPT
• HCPCS
• FHIR
• HL7
• HIPAA
• Value-Based Care
• ACO Programs
  
  

Preferred Qualifications

• Experience with payer modernization initiatives.
• Exposure to digital healthcare transformation.
• Experience supporting cloud-based healthcare platforms.
• Familiarity with healthcare interoperability standards.
• Knowledge of AI-driven healthcare analytics.
• CBAP, CCBA, PMI-PBA, or similar Business Analysis certifications.
  
  

Soft Skills

• Excellent communication and presentation skills.
• Strong stakeholder management abilities.
• Ability to communicate effectively with clinical, operational, and technical teams.
• Strong analytical and critical thinking skills.
• Excellent documentation skills.
• Ability to prioritize multiple initiatives simultaneously.
• Detail-oriented with strong problem-solving capabilities.
  
  

Success Metrics

The successful candidate will demonstrate:

• Improved provider network operational efficiency.
• Enhanced care management workflows.
• Accurate and complete business requirements.
• Successful delivery of healthcare technology initiatives.
• Reduced implementation defects through comprehensive UAT.
• Improved provider data quality.
• Better stakeholder satisfaction.
• Measurable improvements in quality metrics and operational performance.
• Successful support of regulatory and compliance initiatives.
  
  

Preferred Industry Experience

Candidates with experience in the following organizations or similar healthcare payer environments are highly preferred:

• Client (Optum)
• Elevance Health (Anthem)
• CVS Health / Healthcare
• Client Healthcare
• Humana
• Molina Healthcare
• Centene
• Healthcare
• Client Cross Plans
• Highmark
• GuideWell
• CareSource
• Healthfirst
• Oscar Health
• Alignment Healthcare
  
  

Ideal Candidate Profile

The ideal candidate is an experienced Healthcare Business Analyst with deep expertise in Provider Network operations and Care Management programs. They possess strong knowledge of healthcare payer workflows, provider lifecycle management, clinical operations, regulatory standards, and healthcare data analysis. They excel at translating complex business requirements into actionable functional specifications, collaborating across clinical and technical teams, and delivering technology solutions that improve operational efficiency, provider performance, care quality, and regulatory compliance in a healthcare payer environment.