About us:
Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
Brief Summary of purpose:
The Business Systems Analyst III works on initiatives of complex scope and is responsible for defining scope and objectives; eliciting, analyzing, and documenting SMART functional and non-functional business requirements; documenting current-state and future-state workflows; developing data/file mappings and technical specifications; and partnering with stakeholders to prioritize requirements. The role collaborates with Project Managers on work estimates, deliverable and task breakdowns, risk management, and project-plan updates. The BSA III assesses system capabilities and interdependencies, collaborates with design and development teams, provides technical guidance, and identifies alternative solutions that balance business and technical needs.
ResponsibilitiesPrimary Job Responsibilities:
- Provides ongoing business systems analysis and production support for Enrollment, Billing & Provider (EBP) applications and processes, with particular focus on eligibility, enrollment, billing, reconciliation, and outbound vendor file processing.
- Serves as a lead analyst for complex eligibility and vendor file initiatives, including requirements gathering, business rules analysis, file mapping, BRD development and updates, testing coordination, defect resolution, and implementation support.
- Analyzes and documents healthcare EDI and enrollment-related data requirements and mappings, including 834 and 820 transaction processing and associated reconciliation workflows.
- Partners closely with business stakeholders, developers, QA, EDI/Integration teams, and external vendors to translate business needs into technical requirements, resolve data or processing issues, and coordinate testing and implementation activities.
- Supports annual Medicare and other product implementation activities by performing impact assessments, identifying affected applications and files, defining required changes, documenting requirements, and coordinating readiness across impacted units.
- Supports operational reconciliation and process-improvement initiatives, identifying opportunities to automate or standardize file validation, exception handling, monitoring, and business handoffs.
- Demonstrated experience with healthcare enrollment, eligibility, billing, provider data and/or EDI transaction processing strongly preferred. Experience with 834/820 transactions, vendor file interfaces, reconciliation processes, and healthcare payer systems is highly desirable.Core Competencies and Performance Expectations
- Advanced analytical, problem-solving, conceptual-thinking, and business-acumen skills.
- Excellent interpersonal, verbal, and written communication, including effective meeting and requirements-session facilitation.
- Ability to prioritize, organize, follow up, and meet critical deadlines across competing demands.
- Open communication, adaptability, initiative, sound judgment, and a continuous-improvement mindset.
- Ability to work independently while escalating complex issues appropriately
Qualifications
- Education:
- Bachelor Degree equivalent experience preferred
Experience:
5–10 years of business analysis, SMART requirements documentation, scope management, elicitation, process mapping, and related experience, or equivalent experience. SQL / Query writing preferred. Experience applying database concepts in healthcare management. Prior health plan operations experience preferred
Pay Range Disclosure:In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 128,000 annually which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
