Lead Business Systems Analyst - Interoperability & Electronic Prior Authorization (ePA)

We are seeking an experienced Lead Business Systems Analyst (BSA) to drive business analysis, requirements management, and stakeholder coordination for healthcare interoperability and Electronic Prior Authorization (ePA) initiatives. This role will serve as the primary liaison between business, technology, vendor, and operational teams to ensure successful implementation of CMS interoperability mandates and prior authorization workflows, including CRD (Coverage Requirements Discovery), DTR (Documentation Templates and Rules), PAS (Prior Authorization Support), Patient Access, Provider Access, and Payer-to-Payer solutions., * Own and manage end-to-end business and functional requirements for interoperability and ePA initiatives, including CRD, DTR, and PAS implementations.

• Lead requirements gathering sessions with business, operations, clinical, and technology stakeholders.
• Translate regulatory mandates, business needs, and operational processes into detailed business and technical requirements.
• Maintain complete requirements traceability from CMS regulations through design, development, testing, and implementation.
• Create and manage business process flows, use cases, user stories, and functional specifications.

Vendor Management

• Serve as the primary day-to-day requirements lead and liaison with external vendors, including Availity and other implementation partners.
• Review and validate vendor assumptions, solution designs, workflows, and implementation approaches.
• Identify and track project gaps, risks, dependencies, issues, and key decisions.
• Ensure vendor deliverables align with business objectives, compliance requirements, and implementation timelines.

FHIR & Interoperability Analysis

• Analyze and support interoperability workflows related to:
• Coverage Requirements Discovery (CRD)
• Documentation Templates and Rules (DTR)
• Prior Authorization Support (PAS)
• Patient Access APIs
• Provider Access APIs
• Payer-to-Payer Data Exchange
• Understand FHIR-based data exchange requirements and associated resource mappings.
• Collaborate with API and integration teams to assess business process impacts and implementation requirements.
• Support interoperability solution design discussions and requirements validation.

Cross-Functional Coordination

Coordinate and collaborate across multiple business and technology teams, including:

• Utilization Management (UM)
• Medical Policy
• Clinical Operations Teams
• API Development Teams
• Vendor Partners (Availity, Cognizant, Prime, etc.)
• Enterprise Architecture
• Quality Assurance and Testing Teams
• Program and Project Management stakeholders

Testing & Implementation Readiness

• Define business test scenarios, acceptance criteria, and validation requirements.
• Coordinate end-to-end testing activities across multiple systems and teams.
• Validate provider and member workflows to ensure business readiness.
• Support CMS interoperability compliance and regulatory readiness efforts.
• Participate in User Acceptance Testing (UAT) and implementation planning activities.

Do you have experience in Vendor relationship management?, Do you have a Bachelor’s degree?, The ideal candidate will possess deep healthcare payer experience, strong business analysis expertise, vendor management skills, and a solid understanding of API integrations and interoperability frameworks., * 8+ years of experience as a:

• Business Systems Analyst (BSA), or
• Product Owner, or
• Product Manager
• Strong healthcare payer industry experience.
• Hands-on experience with Prior Authorization processes and workflows.
• Experience managing and coordinating third-party vendors and implementation partners.
• Experience with API integrations and system integration projects.
• Excellent requirements elicitation, facilitation, and stakeholder management skills.
• Strong analytical, problem-solving, and communication abilities.

Highly Preferred Qualifications

• Experience with FHIR (Fast Healthcare Interoperability Resources).
• Knowledge of CMS-0057-F interoperability regulations.
• Experience implementing or supporting CRD, DTR, and PAS workflows.
• Knowledge of HL7 standards.
• Experience with healthcare interoperability programs and initiatives.
• Understanding of Utilization Management (UM) workflows.
• Familiarity with Medical Policy systems and processes.
• Experience working with healthcare APIs and digital healthcare ecosystems., * Regulatory compliance analysis and requirements management.
• Healthcare interoperability and data exchange standards.
• Business process modeling and workflow analysis.
• Agile/Scrum delivery methodologies.
• Cross-functional leadership and stakeholder engagement.
• Risk, issue, and dependency management.
• End-to-end testing coordination and business validation.

Education

· Bachelor’s degree in Business, Healthcare Administration, Information Systems, Computer Science, or a related field.

· Relevant healthcare, business analysis, or interoperability certifications are a plus.

$55 - $75 an hour - Contract, Pulled from the full job description

• 401(k), * 401(k)