Business Analyst.

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 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 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.