Innova Solutions · 8 hours ago
Lead Claims Business Analyst
Philadelphia, PA
Contract
Onsite
Senior Level
$52/hr - $55/hr
5+ years expInnova Solutions is a global leader in technology and business transformation solutions, and they are seeking a Lead Claims Business Analyst. The role involves developing policy enforcement requirements, collaborating with internal and external stakeholders, and ensuring compliance with business requirements related to claims management.
Artificial Intelligence (AI)Business Information SystemsCloud Data ServicesConsultingCyber SecurityInformation TechnologyInfrastructureIT ManagementMachine LearningSoftware
Responsibilities
Develop policy enforcement requirements based on medical and claim payment policy criteria. Types of enforcement include but are not limited to claim system, prior authorization, desk level procedures, and post-payment review
Collaborate with internal business colleagues within the department to gain an understanding of policy criteria, and medical coding rules, to assess systems capabilities
Collaborate with other departments and external vendors to ensure the accurate implementation of policies according to business requirements
Identify policies that require manual review of policy criteria when systematic enforcement is not an option or not recommended
Provide timely documented feedback on issues identified at the system level and execute escalation procedures, including corrective action plans, as applicable
Provide quality assurance through development and review of claims data utilization reports to ensure assigned policies are enforced according to business requirements
Provide review and resolution of claims incidents resulting from policy set-up issues. Follow-through until all impacted claims are identified and adjusted and provide proper reporting
Perform root cause analysis to determine source of policy set-up issues. Perform User Acceptance Testing in collaboration with external vendor
Provides input to regulatory and other oversight teams regarding adherence to compliance requirements
Qualification
Required
Bachelor's degree in relevant discipline or equivalent work experience
Minimum of five years related Claims, Operations or Business Requirement Development experience
Proven competency with various business tools, such as Microsoft Excel, Word, PowerPoint, SharePoint, and Teams
Preferred
Current coding certification i.e., CCS, CPC, RHIA, RHIT
Working knowledge of Healthrules Payer or Source claims processing system
Experience in Medical coding
Familiarity with CMS processing rules
Benefits
Medical & pharmacy coverage
Dental/vision insurance
401(k)
Health saving account (HSA)
Flexible spending account (FSA)
Life Insurance
Pet Insurance
Short term and Long term Disability
Accident & Critical illness coverage
Pre-paid legal & ID theft protection
Sick time
Other types of paid leaves (as required by law)
Employee Assistance Program (EAP)
Company
Innova Solutions
Innova Solutions is an IT company that specializes in data analytics, cloud computing, cyber security, and machine learning.
10001+ employees
H1B Sponsorship
Innova Solutions has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (452)
2024 (399)
2023 (290)
2022 (78)
2021 (36)
2020 (98)
Funding
Current Stage
Late StageTotal Funding
unknown2012-01-01Private Equity
Leadership Team
Raj Sardana
Founder, Chairman, & CEO
A
Atul Gambhir
Chief Information & Product Officer
Recent News
2025-12-15
EIN Presswire
2025-08-01
Company data provided by crunchbase