Job Summary

This role supports health care claims operations by configuring and validating claim processing on Xcelys Claims Medical and QNXT Claims Medical platforms ensuring accurate adjudication for medical claims. The specialist uses strong domain knowledge in claims and medical benefits to improve cycle time reduce errors and support a high quality member and provider experience while working remotely during day shifts.

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

BSc Nursing with 2-3 years of clinical experience .