Clinical Business Analyst

* Description
* Clinical Business Analyst
The Clinical Business Analyst is responsible for leading the design, documentation, configuration, testing, training, and ongoing support of prior authorization (PA) automation solutions using MCG clinical decision support tools and Utilization Management (UM) platforms. This role serves as a key liaison between clinical, operational, and technical stakeholders to ensure automated PA workflows align with evidence-based guidelines, regulatory requirements, and business objectives.
The ideal candidate brings deep expertise in clinical utilization management, payer operations, and healthcare IT systems, with a proven ability to translate complex clinical and regulatory requirements into scalable, automated solutions.

Key Responsibilities
Prior Authorization & UM Automation
Lead end-to-end analysis and implementation of prior authorization automation across MCG tools and UM platforms
Design and document automated PA workflows, decision logic, and exception handling aligned with clinical guidelines and payer policies
Configure MCG guidelines, rules, and integrations to support automated and semi-automated authorization decisions
Partner with UM operations to optimize workflows, reduce manual review, and improve turnaround times
Business Analysis & Solution Design
Elicit, analyze, and document business, clinical, and functional requirements
Translate requirements into detailed functional specifications, user stories, and process flows
Ensure traceability between business requirements, system configuration, and testing outcomes
Support solution design decisions with data, operational insights, and clinical best practices
Testing & Quality Assurance
Develop and execute test strategies, test cases, and validation plans for PA automation
Coordinate and support unit, integration, UAT, and regression testing
Validate clinical accuracy, compliance, and operational readiness prior to production release
Training, Deployment & Support
Create training materials and deliver training for UM nurses, providers, and operational staff
Support go-live activities and provide post-implementation stabilization and optimization
Act as a subject matter expert (SME) for PA automation issues, enhancements, and defect resolution
Stakeholder Collaboration & Governance
Collaborate with clinical leadership, UM operations, IT, vendors, and compliance teams
Ensure solutions comply with CMS, NCQA, state regulations, and payer policies
Support audit readiness and documentation related to prior authorization decisions

* Skills
* Business analysis, Prior Authorization, MCR tools, End to End, Prior Authorization automation, UAT

* Top Skills Details
* Business analysis,Prior Authorization,MCR tools,End to End,Prior Authorization automation,UAT

* Additional

Skills & Qualifications
* Required Qualifications
Bachelor's degree in Healthcare, Nursing, Health Informatics, Business, or a related field (or equivalent experience)
5+ years of experience as a Business Analyst in healthcare, payer operations, or health IT
Strong hands-on experience with MCG (formerly Milliman Care Guidelines)
Proven experience with Utilization Management and Prior Authorization workflows
Demonstrated experience designing or supporting clinical decision support or automation solutions
Strong documentation skills, including requirements, workflows, and test artifacts
Experience working in Agile, hybrid, or waterfall delivery environments

Preferred Qualifications
Clinical experience (e.g., RN, LPN, MD, Pharm

D) or significant clinical workflow experience

Experience with UM platforms (e.g., Predictal, Helios, Guiding Care, Tru Care, Epic UM, or similar)
Experience integrating PA systems with EDI, APIs, or provider portals

Experience with Jira
Core Competencies
Clinical and operational understanding of utilization management
Expertise in prior authorization policy interpretation and automation
Strong analytical and problem-solving skills
Excellent written and verbal communication
Ability to influence without authority and manage complex stakeholder relationships
Detail-oriented with a focus on quality, compliance, and patient impact

* Experience Level
* Intermediate Level

* Job Type & Location
* This is a Contract position based out of Saint Paul, MN.

* Pay and Benefits
* The pay range for this position is $50.00 - $65.00/hr.
Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:

* Medical, dental & vision

* Critical Illness, Accident, and Hospital

* 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available

* Life Insurance (Voluntary Life & AD&D for the employee and dependents)

* Short and long-term disability

* Health Spending Account (HSA)

* Transportation benefits

* Employee Assistance Program

* Time Off/Leave (PTO, Vacation or Sick Leave)

*…