The Senior Operations Business Analyst provides advanced analytical, reporting, and problem‑resolution support across Claims, Customer Service, Enrollment & Billing, and Appeals & Grievances. The role requires deep expertise in Medicare Advantage appeals and grievances, claims processing workflows, data models, and regulatory reporting. This position partners with operational, technical, clinical, and compliance teams to analyze trends, validate data universes, optimize processes, and ensure operational and regulatory performance standards are met. The analyst leverages strong technical acumen, including FACETS, reporting tools, and data extraction techniques, to drive improvements, ensure compliance, and support business decisions.

• Serve as a department project lead for corporate and departmental initiatives, including those involving appeals & grievances reporting, claims operational enhancements, and regulatory changes. Provide written and verbal status updates, identify risks, perform root cause analyses, and recommend process improvements.
• Serve as a department project lead for department/corporate projects and/or maintenance activities as assigned. Communicate project team status updates verbally and in writing to all team members. Identify projects risks and contingencies. Conduct root cause analysis and identify process improvement opportunities.
• Elicit and document detailed business requirements for system enhancements, data reporting needs, regulatory changes (CMS, State, NCQA), and operational process updates.
• Anticipate operational and regulatory problems before they occur, document solution options, work with stakeholders to implement changes, and consider long‑range impacts to appeals, grievances, claims, and administrative workflows.
• Proficiently support four (4) or more subject matter areas as a subject matter expert, including Medicare Advantage appeals & grievances processing, claims adjudication, regulatory reporting, data validation, and operational performance analytics.
• Mentor less experienced staff, including informal coaching on reporting, appeals workflows, systems navigation, and documentation standards. Support internal and external customers by answering inquiries and producing clear process documentation.
• Build strong working relationships across departments (Appeals & Grievances, Claims, IT, Regulatory, Customer Service). Summarize analytical findings, trends, and reporting outcomes in a clear and digestible manner. Facilitate meetings, prepare agendas, minutes, and communicate delays, risks, and impacts.
• Perform application testing for system updates, maintenance, and regulatory changes. Execute test scenarios, validate appeals and claims configurations, evaluate defects for operational/regulatory impact, and document findings.
• Demonstrate working knowledge of targeted system applications and tasks, including FACETS tables and reporting data structures.

Skills

• Ability to analyze data, identify trends, determine impacts, and develop solutions for system or process changes affecting claims, appeals & grievances, and regulatory reporting.
• Ability to act as a liaison and recommend solutions across departments including Appeals & Grievances, Claims, Customer Service, IT, and external partners.
• Strong written and verbal communication skills, able to translate technical reporting, regulatory requirements, and operational data into business‑friendly insights.
• Ability to prioritize multiple reporting, analytical, and project tasks with minimal supervision and adapt to changing regulatory or operational priorities.
• Ability to create and run queries and extract datasets supporting claims processing, appeals & grievances, and regulatory requirements.

Knowledge

• Knowledge of the healthcare industry, Medicare Advantage appeals & grievances regulatory requirements (CMS, Act 68, ERISA, HIPAA, NCQA), and claims processing operations.
• Knowledge of data processing concepts, including use of Microsoft Office Suite, Crystal Reporting, and data modeling used for operational and regulatory reporting. 
• Understanding of corporate reporting requirements, data validation techniques, and CMS universe specifications.
• Ability to lead meetings and present findings to management and cross‑functional teams.

Experience

• 3 years of experience working with integrated business systems handling claims, appeals & grievances, membership, and customer service processes.
• Experience producing, analyzing, and delivering routine and ad hoc reports, including regulatory datasets (CMS universes) and operational performance dashboards.
• Experience navigating peripheral FACETS systems and appeals/claims modules; strong working knowledge of reporting capabilities and data validation.

Education, Certification, and Licenses

• Bachelor’s degree in business administration, health administration, information systems, computer science, or related field preferred.

Work Environment

Working environment includes typical office conditions.

Physical Demands 

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.
• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Other

• Ability to communicate effectively with internal and external personnel. Travel may be required, including potential overnight excursions.
• Ability to communicate effectively with all levels of personnel, both internal and external.

The job demands described here are representative of those that must be met by an employee to successfully perform the functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations and for establishing performance standards. The percentage of time spent performing the various job duties is not absolute. The incumbent shall perform all other functions and/or be cross trained as shall be determined by the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole. This document is not a contract for employment. Employment is at-will.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.