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Business Systems Specialist - IT Operations and Programs Job in Wellesley, MA

Under the direction of the Director, Technology Operations and Programs, and in collaboration with Dell Services Claims Operations leadership, incumbent is responsible for maintaining the integrity of, and providing oversight and coordination for the maintenance of code sets, business logic and user interface for the OHI Claims application and HPHC’s Pricer application. This individual is also responsible for the management of business requirements definition, release management, and coordinating user acceptance testing process for both the claim and pricing systems. Responsibilities also include managing cross functional communication with both HPHC and Dell business units as well as applicable vendors, as required, to maintain system integrity.


1.Oversees all maintenance processes, development of business requirements, and user acceptance test plans for enhancements for Oracle Health Insurance (OHI Claims) and HPHC’s selected Pricer system. Tracks deliverables, timelines, maintains documentation, reports on progress, and escalates issues to the appropriate forum for resolution.
2.Participates in UAT activities, as needed.
3.Functions as liaison with application vendors, maintaining standard processes to support ongoing communication with regards to system upgrades, changes, issue resolution; coordinates communication and roll out across affected business units
4.Serves as subject matter expert in collaboration with department trainers and documentation specialists, with regard to the communication and training of staff for new systems as well as any upgrades/enhancements. Assures that written documentation is revised to reflect current business practices.
5.Identifies and recommends to the department leadership new functionality and/or enhancements that streamline claims pricing and claims adjudication work activity, and are likely to have a positive return on investment.
6.Serves as a department liaison with business units managing enhancement requests and prioritization, and technical documentation. Coordinates business unit representation for the purpose of discussing and resolving issues as they pertain to OHI Claims and Pricing applications.
7.Serves as the primary contact for day-to-day coordination with the claims system and Pricer vendor(s) including defect management, release planning and enhancement projects.
8.Represents Technology Operations and Programs on the Corporate Change Board (CCB).
9.Assures that the claims system is synchronized with downstream application and processes, with regard to codes, messages, etc. that impact claim processing and reporting. Develops business processes and oversees implementation and UAT of new codes, messages, etc., to assure appropriate mapping.
10.Maintains and/or serves as SME for specified system tables and other system configuration (letters, reference tables and rules) within the claims and pricing systems that require periodic updates.
11.Oversees the development of new business requirements and maintenance of existing business requirements, and User Acceptance Test for Messages, Message Groups, and Pend Reasons, and submit Service Request for enhancements to the OHI system. Track deliverables, timeline, maintains documents, reports on progress, and escalate issues to the appropriate forum for resolution. Assessment and planning of Messages, Message Groups, and Pend Reason Codes needs based on the ongoing delivery of OHI Releases and Patches from vendor for the OHI system.
12.Maintains and/or serves as SME for ongoing maintenance of OHI Naming Convention Standards for Messages, Message Groups, and Pend Reason Codes and Descriptions to ensure that standards are being followed and documentation is up to date. Completes periodic audits each year on the use / adherence of OHI Naming Convention Standards for Messages, Message Groups, and Pend Reason Codes and Descriptions. Propose changes to standards for appropriate review and approval, as needed.
13.Coordinates activities to define, map, test, and implement HIPAA code mapping from OHI Messages and Pend Reasons for the MMS 835 and 277 tables and other applications/tables as needed. Communicate new / changes to existing mapping to representatives of downstream systems, e.g., OCSA (OHI Staging Area), Member Statement, EOP, 835, etc. Serves as SME for ongoing review, approval, and signoff of documentation for HIPAA mapping rationale and guidelines for Messages and Pend Reason Codes.
14.Identifies and anticipates system issues and proactively collaborates with stakeholder(s) to prevent /minimize system disruption.
15.Participates on cross functional departmental, interdepartmental and project teams as required.
16.Coordinates assessment and planning of Business Continuity needs for claims and pricing systems.
17.Participate in system demonstrations for prospective OHI customers as needed.

Required Experience
•Bachelor’s degree required and/or equivalent experience in Information Systems
•Minimum 5 years Business analyst/Project Management in a health care related environment.
•Excellent interpersonal and communication skills, with the ability to interact with all levels of employees, vendors and providers.
•Ability to work in a dynamic environment that involves priority setting and handling multiple tasks simultaneously.
•Excellent writing and documentation skills; superior attention to detail.
•Strong organizational and creative problem-solving skills with ability to work independently.
•Knowledge of health care, specifically claims processing, HPHC systems and business process.
•Demonstrated experience in working cross-functionally in a matrix or distributed model organization.
•Foundational knowledge of database structure, and user acceptance testing experience a plus.
•Excellent skills and ability to work with various software packages, including, but not limited to, Microsoft Word, Excel, MSProject, Powerpoint, Visio and Access databases.

Job Location
Wellesley, MA US

Requirements Elicitation|Facilitation|Problem Solving|Business Process Management (BPM)|Project Management|User Experience|Process Flow Diagrams
Additional Skills
No Additional skills required for this job.
Health Insurance|Dental Insurance|Vision Insurance|Life Insurance|401(k)|Tuition Reimbursement|Flex Schedule
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USA USA: Wellesley, MA
Harvard Pilgrim Health Care
1600 Crown Colony
Quincy, MA 02169
Dina Southwell
Full Time
Salary / Pay:
Systems Analysis
Health Care & Pharmaceutical
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