SPE-Claims HC

Job Summary

Responsibilities

• Analyze health care claims on Xcelys Claims Medical and QNXT Claims Medical systems to ensure accurate benefit application and financially correct outcomes that support timely payments and customer satisfaction.
• Review claim adjudication rules and configurations for medical benefits to maintain alignment with product policies regulatory requirements and operational guidelines while minimizing rework and claim reversals.
• Execute end to end testing of claims adjudication scenarios in Xcelys and QNXT environments to validate pricing logic accumulators and edits before production deployment and reduce downstream defects.
• Investigate claim exceptions denials and pended items by tracing benefit setup provider data and member eligibility to identify root causes and propose sustainable corrective actions.
• Collaborate with business analysts and operations teams to translate claims business requirements into clear system changes for Xcelys and QNXT that enhance processing efficiency and quality.
• Perform impact analysis for configuration updates on related claim flows including coordination of benefits prior authorization and referrals to prevent unintended disruptions.
• Document standard operating procedures and reference guides for recurring claims scenarios so that operations teams can resolve issues consistently and accurately.
• Monitor daily claims production reports to identify processing trends error patterns and aged inventories and then recommend targeted improvements for throughput and accuracy.
• Support internal quality reviews by providing evidence of claim calculations rule interpretations and configuration decisions that demonstrate compliance with audit standards.
• Respond to queries from cross functional stakeholders regarding claim outcomes by explaining configuration logic benefit interpretation and applicable business rules in an accessible manner.
• Assist in continuous improvement initiatives focused on automation and simplification of claims adjudication steps which help lower operational cost and enhance member outcomes.
• Coordinate with technology partners for defect triage and resolution where system behavior differs from documented design and ensure that validated fixes are deployed and tracked.
• Maintain current knowledge of health care claims practices codes and payer guidelines so that configuration and adjudication decisions remain aligned with industry expectations and organizational policies.

Qualifications

• Apply practical experience in medical claims adjudication to interpret complex benefit structures cost sharing rules and coverage limitations in a consistent and reliable manner.
• Use hands on expertise with Xcelys Claims Medical to configure validate and troubleshoot benefit rules edits and accumulators for a wide range of medical claim types.
• Leverage working knowledge of QNXT Claims Medical including claim workflows plan build and pricing configurations to support stable production operations.
• Demonstrate strong domain understanding of claims life cycle encompassing intake adjudication adjustments recoveries and member and provider impacts.
• Communicate clearly in a remote work from home setting using collaboration tools to align with distributed teams during standard day shifts.
• Exhibit analytical and problem solving skills when interpreting data reconciling claim discrepancies and recommending targeted system or process changes.
• Show adaptability by learning new payer products regulatory updates and platform enhancements that influence medical claims adjudication and configuration decisions.

Certifications Required