Clinical BSA

Role: Senior Clinical BSA

Location: Remote USA

Seeking a Senior Clinical BSA with 10+ years of healthcare payer experience, focused on Population Health, Utilization Management (UM), and Care/Case Management (CM). This role acts as a clinical + functional SME, supporting Medicaid and Medicare initiatives to improve care delivery, outcomes, and compliance.

Duties: Population Health, UM & Care Management

• Clinical SME for systems supporting Pop Health, UM, and CM
• Analyze and document end to end clinical workflows, including:
  • Care plans
  • Prior authorizations & utilization review
  • Clinical assessments
  • Care coordination & transitions of care
• Convert clinical and business needs into:
  • Functional requirements
  • User stories
  • Acceptance criteria
• Support initiatives around:
  • Risk stratification
  • Care gap identification/closure
  • Member outreach
  • Outcomes and quality tracking

Clinical Process & Requirements Analysis

• Perform gap analysis, impact analysis, and process modeling
• Create and maintain:
  • BRDs / FRDs
  • Workflow diagrams
  • Data mappings & traceability matrices
• Partner with clinical ops, medical management, and compliance teams
• Ensure solutions align with evidence based care models and regulations

Data Analysis & Reporting

• Use SQL to validate:
  • Care management data
  • Authorization decisions
  • Clinical outcomes & quality measures
  • Utilization metrics
• Work with data/reporting teams to ensure clinical data accuracy

Stakeholder Collaboration

• Act as a bridge between:
  • Clinical teams (nurses, care managers, medical directors)
  • Business stakeholders
  • IT, data, and integration teams
• Lead cross functional sessions
• Present complex concepts to non technical stakeholders
• Manage backlog and priorities in Agile/Scrum

Testing, Quality & Compliance

• Define and support UAT
• Validate clinical workflows and authorization logic
• Support defect triage with QA teams
• Ensure compliance with:
  • HIPAA
  • CMS guidelines
  • State Medicaid regulations
• Support audits and PHI/PII security reviews

Required:

• Bachelor's or Master's degree (IS, CS, Business, or related)
• 10+ years as a Clinical / Healthcare BSA (payer environment)
• Strong expertise in:
  • Population Health
  • Utilization Management
  • Care / Case Management
• Deep knowledge of Medicaid & Medicare workflows
• Strong documentation skills (BRDs, FRDs, user stories, STTMs, process maps)
• SQL proficiency for clinical and utilization data validation
• Experience with clinical and care management platforms
• Strong communication and stakeholder management skills
• Agile/Scrum experience