Senior Business Analyst – Pharmacy (RCM, Billing & Financial Reconciliation)

Overview

We are seeking a highly experienced Senior Business Analyst with deep expertise in specialty/infusion pharmacy, medical billing, and financial reconciliation to support enterprise SaaS implementations. This role serves as a critical liaison between clients, operations, product, and engineering teams to define business requirements, design future-state workflows, and ensure successful delivery of Revenue Cycle Management (RCM) solutions.

The ideal candidate brings strong domain knowledge in pharmacy billing, claims adjudication, payment posting, and reconciliation, and plays a key role across the full client lifecycle—from pre-sales through implementation and post-go-live optimization.

Key Responsibilities

Delivery & Strategic Execution

• Lead complex and enterprise-wide implementations with multiple integrated workstreams

• Own RCM functional track deliverables, ensuring alignment across stakeholders

• Define governance standards, implementation plans, and risk mitigation strategies

• Drive future-state workflow design across pharmacy operations and revenue cycle processes

• Manage release coordination, dependencies, and cross-functional execution

Pharmacy Billing & Revenue Cycle Expertise

• Serve as Subject Matter Expert (SME) in:

  • Medical and pharmacy billing (specialty and infusion)

  • Claims lifecycle management (submission, adjudication, reversals, rebilling)

  • Payment posting, ERA (835), and financial reconciliation

• Optimize workflows to improve:

  • Clean claim rate and first-pass yield

  • Denial management and resolution

  • Days in Accounts Receivable (A/R)

  • Net collections and revenue leakage prevention

• Analyze and resolve billing discrepancies including underpayments, overpayments, and unapplied cash

• Ensure alignment between pharmacy systems, billing platforms, clearinghouses, and financial systems

Client Engagement & Product Collaboration

• Work closely with clients to gather and define RCM and operational requirements

• Translate client needs into business and system requirements for product development

• Provide business case justification for product enhancements

• Participate across the full lifecycle:

  • Request for Proposal (RFP )esponses and product demos

  • Implementation, testing, and go-live

  • Post-production support and optimization

• Partner with Product Managers on roadmap and knowledge sharing

Requirements & Process Analysis

• Elicit, document, and manage business and system requirements (BRDs, design documents)

• Develop process workflows using tools such as Visio

• Analyze current systems and identify improvement opportunities

• Assess impacts of proposed solutions across systems, workflows, and stakeholders

Technical & Data Capability

• Work within SaaS environments utilizing Agile/Scrum and full SDLC practices

• Support system configuration and ensure alignment with business requirements

• Define data requirements and support reporting and reconciliation processes

• Utilize tools such as SQL and Crystal Reports for data validation and analysis

• Support integrations across APIs, FHIR/HL7, claims (NCPDP/837), and remittance (835)

Validation & Quality Assurance

• Lead User Acceptance Testing (UAT) strategy, planning, and execution

• Participate in system validation prior to release

• Triage and resolve escalated defects in collaboration with QA and engineering

• Ensure delivered solutions meet client, operational, and financial expectations

Stakeholder & Leadership Responsibilities

• Act as a trusted advisor to clients and internal leadership

• Lead cross-functional discussions and align business and technical teams

• Support training initiatives and knowledge transfer

• Mentor junior analysts and promote BA best practices

Operational Excellence & Business Impact

• Drive improvements in onboarding, billing accuracy, and operational efficiency

• Support standardization, scalability, and adoption of solutions

Compliance & Governance

• Ensure adherence to HIPAA, DEA, State Board, and regulatory requirements

• Maintain compliance with Inovalon policies and procedures

• Support audit readiness and financial accuracy

Qualifications

Education

• Bachelor’s Degree in Healthcare, IT, Business, or related field (or equivalent experience)

Experience

• 5+ years of Business Analysis experience in healthcare or SaaS

• 2+ years of experience in medical billing and financial reconciliation

• Experience in specialty or infusion pharmacy environments preferred

• Strong background in Revenue Cycle Management (RCM)

Working Conditions

• Primarily sedentary role involving extended periods of sitting and computer use

• Occasional lifting (up to 10 pounds)

• Ability to work in a fast-paced, dynamic environment

• Travel for this position will include up to 10%