Manager Business Systems Analysis

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Primary Responsibilities:

• Lead end-to-end business analysis efforts across claims adjudication, payment integrity reviews, appeals, audit recovery, and FWA investigations
• Drive revenue-based opportunity identification, including duplicate claims detection, pricing/contract errors, eligibility misalignment, underpayment/overpayment root causes, and leakage prevention
• Serve as the primary liaison between business sponsors, PI SMEs, actuarial partners, provider teams, and technical build teams
• Interpret healthcare guidelines, policies, contract rules, and benefit logic and translate them into actionable business rules and functional requirements
• Lead formulation, validation, and refinement of requirements, acceptance criteria, and business rule logic for PI interventions
• Review data quality, impact assessments, and financial projections across PI initiatives
• Mentor and guide Business Analysts, ensuring consistency, analytical rigor, and adherence to documentation standards
• Lead complex issue remediation: deep-dives into claim-level patterns, provider-level anomalies, pricing variances, member eligibility mismatches, and systemic process gaps
• Support leadership-level reporting, audit responses, regulatory inquiries, and controls documentation
• Participate in roadmap design, prioritization sessions, operational reviews, and cross-functional working groups
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

• Bachelor's degree in Business, Health Administration, Finance, or related field
• 8+ years of Business Analysis experience in US Healthcare
• Experience facilitating cross-functional workshops, JAD sessions, and requirements reviews
• Proven experience interpreting claims adjudication rules, payment policies, or benefit structures
• Domain & Data Expertise
  • Experience working with Provider RCM data (billing patterns, coding, prior auth, clinical documentation alignment)
  • Experience with PI-specific reporting, including:
    • Duplicate claim identification
    • Pricing anomalies
    • Eligibility issues & benefit mismatches
  • Understanding of actuarial reporting, forecasting dashboards, or cost-of-care analytics used for PI impact sizing
  • Familiarity with Call Center datasets (member & provider contact/call data) for identifying navigation issues, provider abrasion signals, or member experience indicators tied to PI
  • Exposure to EHR / Clinical datasets for validating medical necessity, care patterns, and crosswalks to claims
• Proven solid leadership, decision-making, and stakeholder management skills
• Proven excellent analytical and problem-solving skills
• Proven exceptional written and verbal communication
• Proven solid time management; ability to handle multiple priorities
• Proven ability to work independently and collaboratively

• Experience in Claims PI, FWA, Provider Contracting, Billing, or RCM
• Knowledge of SQL for data exploration, validation, and reporting
• Familiarity with PBM, eligibility logic, or provider credentialing systems
• Medicare / Medicaid domain depth