Business / Regulatory Analysts

Job Title: Business / Regulatory Analysts

Remote

Rate -$50/hr on C2C

Business / Regulatory Analysts to support a portfolio of state-mandated regulatory and compliance initiatives across Medicaid and healthcare payer operations. The role will be responsible for translating complex state and federal regulatory requirements into actionable business and system requirements, ensuring full traceability from regulatory intent through design, development, testing, implementation, and post-production validation. This position will play a critical role in supporting 2026/27 regulatory implementation readiness, backlog remediation efforts, and ongoing health-plan-specific compliance initiatives spanning claims, eligibility, reporting, integrations, and operational processes.

Key Responsibilities

• Regulatory Analysis & Compliance
• Analyze and interpret state-specific Medicaid regulations, CMS guidance, mandates, bulletins, and health-plan requirements.
• Assess regulatory impacts across business processes, applications, data, integrations, operational workflows, and reporting.
• Partner with compliance, legal, product, and business stakeholders to clarify regulatory intent and implementation expectations.
• Develop regulatory impact assessments and implementation recommendations.
• Requirements Management
• Elicit, document, and manage business, functional, system, integration, and data requirements.
• Create and maintain:
• Business Requirement Documents (BRDs)
• Functional Requirement Documents (FRDs)
• User Stories and Acceptance Criteria
• Business Rules Documentation
• Process Flows and Use Cases
• Requirements Traceability Matrix (RTM)
• Ensure end-to-end traceability from regulatory mandate through development, testing, deployment, and audit validation. Traceability management
• Regulatory Program Delivery
• Support initiatives involving:
• Claims processing and adjudication
• Member eligibility and enrollment
• Prior authorization
• Provider data and network administration
• Regulatory reporting
• EDI and file exchanges
• Healthcare integrations and APIs
• Health-plan-specific compliance enhancements
• Manage backlog remediation and technical debt items related to prior regulatory releases.
• Cross-Functional Coordination
• Collaborate with:
• Business stakeholders
• Compliance and regulatory teams
• Product Owners
• Solution Architects
• Application Development Teams
• Data and Integration Teams
• Quality Engineering Teams
• Release and Production Support Teams
• Facilitate stakeholder workshops, JAD sessions, requirement reviews, and solution validation discussions.
• Validation & Testing Support
• Partner with QA teams to define regulatory test scenarios and validation strategies.
• Review and validate SIT, UAT, and regression testing results.
• Ensure delivered solutions satisfy regulatory, operational, and audit requirements.
• Support defect triage, root cause analysis, and remediation activities.
• Governance & Audit Readiness
• Maintain complete audit trails and regulatory documentation.
• Support compliance reviews, internal audits, regulatory examinations, and implementation evidence collection.
• Track requirement changes and ensure alignment with approved regulatory interpretations.

Required Qualifications

• Bachelor''s degree in Business, Healthcare Administration, Information Systems, Public Policy, or related field.
• 12+ years of Business Analyst or Regulatory Analyst experience.
• 10+ years of healthcare payer experience.
• Experience supporting Medicaid, Medicare, or Commercial health-plan regulatory initiatives.
• Strong understanding of:
• Claims lifecycle
• Eligibility and enrollment
• Provider management
• EDI transactions (834, 837, 835, 270/271)
• Healthcare data flows and integrations
• Experience creating BRDs, FRDs, User Stories, Process Flows, and RTMs.
• Strong stakeholder management and facilitation skills.
• Experience working within Agile and/or SAFe environments.
• Preferred Qualifications
• Experience with Medicaid regional/state regulatory implementation programs.
• Knowledge of CMS regulations, MMIS, Medicaid managed care operations, and state-specific mandates.
• Experience with Facets, QNXT, HealthRules, or similar core payer platforms.
• Familiarity with:
• Azure DevOps
• Jira
• Confluence
• SQL
• Visio
• Data mapping and integration specifications
• Experience supporting regulatory audits and compliance reviews.

Desired Domain Expertise

• Medicaid Regulatory Programs
• Claims Adjudication
• Member Eligibility & Enrollment
• Provider Data
• Payment Integrity
• Prior Authorization
• Regulatory Reporting
• Healthcare Data Exchange
• API & EDI Integrations
• State-Specific Compliance Requirements
• CMS and Healthcare Regulatory Compliance

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