JOB SUMMARY

Responsible for the end-to-end configuration and lifecycle management of benefits for assigned Lines of Business (LOBs) within QNXT, ensuring approved product, clinical, regulatory, and business requirements are accurately translated into system configuration. This role provides specialized ownership of assigned products from requirements analysis through configuration, maintenance, and production support. The position ensures benefit configuration supports accurate member coverage, cost sharing, claims adjudication, and ongoing product performance.

ESSENTIAL FUNCTIONS

• Own the end-to-end benefit configuration and lifecycle management for assigned Lines of Business, maintaining accountability for configuration accuracy, completeness, and timely delivery.
• Analyze and configure ACA and Large Group benefit requirements and other assigned LOB requirements in accordance with approved product specifications.
• Configure product requirements including cost sharing, MOOP, limits, frequencies, upfront deductibles, accumulators, and other applicable benefit parameters.
• Configure applicable clinical requirements, including preauthorization, referrals, benefit preferences, enrollment-related configurations, setup fees, policies, policy plans, Tailor Reference Configuration, and other required components.
• Create and maintain premium rate tables to support applicable billing requirements across Commercial groups.
• Configure and maintain applicable benefit coverage settings, including UB-1500/ADA, Puerto Rico, USVI, U.S. and Worldwide coverage, and participating and non-participating provider requirements.
• Ensure alignment of benefits configuration across integrated claims system components to achieve expected results and operational efficiency.
• Translate Medical Policy and Coding requirements into applicable benefit configuration, including HCPCS, CPT, CDT, revenue codes, diagnosis, restrictions, TOB, POS, and other applicable coding parameters.
• Manage assigned benefits throughout the product lifecycle, including new configuration, maintenance, amendments, renewals, terminations, and other approved changes.
• Analyze benefit configuration requirements and determine the appropriate QNXT configuration approach based on product design, business rules, and established standards.
• Evaluate relationships and dependencies among benefit components to ensure configuration integrity and consistent claims adjudication.
• Perform configuration self-review to confirm completeness, accuracy, effective dates, parameters, and alignment with approved requirements prior to independent validation.
• Analyze claims adjudication results and provide configuration support to research and resolve benefit-related claims discrepancies.
• Coordinate with Benefit Implementation, Configuration Quality Assurance, Product, Claims, Medical Policy, and other applicable stakeholders to clarify requirements and resolve configuration dependencies.
• Maintain complete and accurate configuration documentation, requirements traceability, supporting evidence, and change records in accordance with established Configuration Management standards and controls.
• Identify recurring configuration issues and opportunities to improve standardization, accuracy, efficiency, reuse, and sustainable benefit configuration practices.

EDUCATION

Bachelor’s Degree (BD) with five (5) to seven (7) years of related QNXT experience minimum 5 years of core system platform experience as an end-user and 5 years of health insurance industry.

LICENSES AND CERTIFICATIONS

COMPETENCIES