Job Description

Identify, document, analyze, and validate configurations within QNXT. Configuration focused on providers, contracts, benefit plan, membership, eligibility, and claims.

Production management and support activities. Monitoring and validating inbound claims (Biztalk, direct submissions, etc. via 837P/I/D), outbound claim encounters (837P/I/D), provider remittance advice (835), and claims status reporting (999, 277).

Develops and communicates system documentation and testing scenarios.

Troubleshooting, testing and coordinating to resolve reported software and/or data issues while providing status to affected teams.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

Education:

  • Associates or Bachelor’s degree in computer related field preferred or equivalent experience in related roles

Years of Experience:

  • Minimum 5 Years QNXT (4.81 5.6 R2) configuration experience
  • At least two (2) years experience with T-SQL

Work Related Experience:

  • Creating and using Microsoft T-SQL Constructs
  • Microsoft Office Suite including Visio
  • Educated and familiar with observing:
  • HIPAA Health Information security & Privacy guidelines and regulations
  • Medicare, and Medicaid/State and Commercial

Specialized Knowledge:

Educated and experienced using:

  • Professional (HCFA 1500), Institution (UB92/UB04) and ADA claim forms
  • ANSI EDI X.12 5010 Transaction Sets: EDI 837i,p,d; EDI 835, 834, 270/271, 276/277, 820
  • Experience reviewing regulator or vendor 5010 companion guides, Washington Publishing Company (WPC) Change Description Guides (CHMs/PDF), and any other regulator requirements documentation to support configuration initiatives
  • Knowledge of claims adjudication systems preferred (MedMC; QNXT)

  • Familiarity with defining, configuring, and supporting:
  • QNXT Claims adjudication, paying and running appropriate import and export processing
  • QNXT Member and enrollment maintenance
  • QNXT Provider maintenance
  • Carrier, Program
  • Sponsor, Policy, Org Policies, Coverage Types , COB, Deductibles, Copay, Etc.
  • Benefit Plans, Benefits, Properties, Org Policies, Rate Codes
  • Provider, Affiliations, Entity Loading/Maintenance, Contract Attachments
  • Pricing: APR-DRG, Dental, ER Visit, FQHC/RHC, Urgent Care, Dialysis, Laboratory, Air & Ground Ambulance, Non-Emergent Transportation, Vision, PT/OT, DME, SNF, Hospice, ASC, Anesthesia, Surgery, Infusion, OB/Prenatal Visits,, Gynecological
  • Configuring Edits and Claim Rules: Max Units, Claim Duplicates, Timely Filing, Diagnosis, Modifier, COB, Service Code Restrictions, CCI, Enrollments, etc.
  • Provider Contracts, Contract Terms, Fee Schedules (UCR, Custom, Dental, etc.), Restriction Groups, Capitation Tables, etc.
  • Medicaid, Medicare UCR configuration
  • Member Internal / External Enrollments
  • Loading and maintaining MRDT and Medical Codes
  • Troubleshooting and inspecting Qnxt PLB and PI databases to address QConnect issues
  • Experience using the Claim, Member and Payment Troubleshooter Modules
  • Rules (Provider, Claim, UM, Auth, Benefits, Members)
  • Microsoft BizTalk Trading Partner, and QNXT Connect (EDI Tables)
  • Troubleshooting and correcting HIPAA errors using the Microsoft System Event Viewer generated from X12 BizTalk processing and importing of EDI 837i,p,d and 834 transaction sets
  • Experienced exporting EDI EDI 837i,p,d, EDI 834 transaction sets from QNXT
  • Experience with QNXT Configuration Migration Utility (CMU/QMU)
  • Experience with QNXT Claims Workflow
  • Medical Claim Review
  • PremiumBilling, A/R account configuration
  • Experience with QNXT Claim Test Pro
  • Experience supporting AutoQ Edits
  • Experience configuring and supporting UM/PA Tempates
  • Experience utilizing SQL to query QNXT and related tables for research purposes (either when setting up new configuration or troubleshooting production issues)

Application Instructions

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