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Qnxt Claims Processing Jobs in Florida (NOW HIRING)

Alivi

Lead Software Engineer Healthcare Payer

Miami, FL · On-site

... claims administration software (e.g., Facets, QNXT, HealthRules, HealthEdge, TriZetto, EZ-CAP, or proprietary platforms). Hands-on experience with: • UB04 and CMS-1500 claim processing • COB ...

Alivi Health

Lead Software Engineer

Miami, FL · On-site

... or claims administration software (e.g., Facets, QNXT, HealthRules, HealthEdge, TriZetto, EZ-CAP, or proprietary platforms). Hands-on experience with: · UB04 and CMS-1500 claim processing · COB ...

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All JobsQnxt Claims Processing JobsQnxt Claims Processing Jobs in Florida

Qnxt Claims Processing information

What is QNXT claims processing?

QNXT claims processing refers to the use of the QNXT software platform, developed by TriZetto, to automate and manage healthcare claims for insurance companies and healthcare providers. This system streamlines the claims lifecycle, from submission and validation to adjudication and payment. It helps organizations improve accuracy, reduce processing times, and ensure compliance with industry regulations. QNXT is widely used in the healthcare industry to increase operational efficiency and enhance member and provider satisfaction.

What are the key skills and qualifications needed to thrive as a QNXT claims processor?

To thrive as a QNXT Claims Processor, you need strong analytical skills, attention to detail, and a solid understanding of healthcare insurance claims, often supported by relevant experience or training. Proficiency in QNXT claims management software, knowledge of ICD-10, CPT coding, and familiarity with HIPAA regulations are typically required. Excellent communication, organizational abilities, and problem-solving skills help you manage claim inquiries and resolve discrepancies effectively. These skills ensure accurate claims adjudication, timely processing, and compliance with regulatory standards, which are vital for operational efficiency in healthcare organizations.

What are some common challenges faced in a QNXT claims processing role, and how can they be effectively managed?

Professionals in Qnxt Claims Processing often encounter challenges such as navigating complex insurance policies, resolving discrepancies in claim data, and meeting tight deadlines while maintaining a high level of accuracy. Effective management of these challenges involves a strong attention to detail, familiarity with Qnxt software functionalities, and clear communication with both internal teams and external providers. Additionally, staying updated on regulatory changes and participating in ongoing training can help streamline processes and reduce errors, making the work more efficient and less stressful.

What is the difference between Qnxt Claims Processing vs Claims Analyst?

AspectQnxt Claims ProcessingClaims Analyst
CertificationsHealthcare IT, Claims Processing CertificationsClaims Processing, Healthcare Billing Certifications
Work EnvironmentHealthcare insurance companies, third-party administratorsInsurance companies, healthcare providers, third-party payers
Job FocusManaging and processing claims using Qnxt softwareAnalyzing claims data, resolving discrepancies, ensuring accuracy

Qnxt Claims Processing specialists primarily focus on managing claims through the Qnxt platform, ensuring efficient processing and compliance. Claims Analysts, on the other hand, analyze claims data, identify issues, and resolve discrepancies. While both roles require knowledge of healthcare claims and certifications, Qnxt Claims Processing roles are more technical and software-specific, whereas Claims Analysts focus on data analysis and problem-solving within the claims process.

Is Qnxt Claims Processing a stressful job?

Qnxt Claims Processing roles can be stressful due to the high volume of claims and strict deadlines. The job requires attention to detail, accuracy, and familiarity with claims management software, which can contribute to work pressure, especially during busy periods.

What are popular job titles related to Qnxt Claims Processing jobs in Florida?

For Qnxt Claims Processing jobs in Florida, the most frequently searched job titles are:

What job categories do people searching Qnxt Claims Processing jobs in Florida look for?

The top searched job categories for Qnxt Claims Processing jobs in Florida are:

What cities in Florida are hiring for Qnxt Claims Processing jobs?

Cities in Florida with the most Qnxt Claims Processing job openings:

Qnxt Claims Processing jobs near you

Claims Quality Business Analyst

Doctors HealthCare Plans, Inc.

Coral Gables, FL • On-site

$85 - $115/hr

Other

Posted 14 days ago

Key responsibilities

  • Monitor claims processing accuracy, timeliness, and compliance with regulatory and contractual requirements.

  • Conduct root cause analyses on claim errors, payment variances, denials, and provider disputes, and develop claims quality monitoring reports.

  • Gather business requirements, analyze claims workflows, and collaborate with IT and vendors on system configuration, testing, and implementation activities.

Job description

Position Purpose

The Claims Quality Business Analyst is responsible for analyzing claims operations, payment accuracy, compliance requirements, and quality performance metrics to identify opportunities for operational improvement, regulatory compliance, and member/provider satisfaction. This position serves as a liaison between Claims, Compliance, Quality, Provider Relations, IT, and Delegation Oversight to support accurate claims adjudication, encounter data integrity, and continuous process improvement.

Responsibilities Claims Quality Oversight
  • Monitor claims processing accuracy, timeliness, and compliance with CMS, AHCA, and contractual requirements.
    • Remittance Advice (RA)
    • Denial Letters/IDN
    • Explanation of Benefits (EOB)
  • Conduct root cause analyses on claim errors, payment variances, denials, and provider disputes.
  • Identify trends related to pended, denied, adjusted, and overturned claims.
  • Develop and maintain claims quality monitoring reports and dashboards.
  • Ensure claims communications accurately communicate payment decisions, denial rationale, member responsibility, provider responsibility, and applicable benefit or payment explanations.
Business Analysis
  • Gather business requirements for system enhancements and claims operational improvements.
  • Analyze claims workflows and recommend process improvements to increase efficiency and reduce rework.
  • Collaborate with IT, Delegates and providers/vendors on claims system configuration, testing, and implementation activities.
  • Perform data validation and user acceptance testing (UAT) for claims-related system changes.
Regulatory and Compliance Support
  • Evaluate claims operations for compliance with CMS Medicare Advantage requirements, AHCA requirements, and internal policies.
  • Lead implementation of regulatory, benefit, and operational changes affecting RA/EOB content, claims reason codes, remark codes, notices, and member/provider-facing explanations.
  • Assist with audit readiness activities, CAP development, and monitoring of corrective actions.
Reporting and Analytics
  • Develop reports tracking:
    • Metrics/Claims turnaround time (TAT)
    • Auto-adjudication rates
    • Financial accuracy
    • Denial trends
    • Encounter submission quality/reporting
    • Claims Adjudicator Production
  • Present findings and recommendations to leadership
Cross-Functional Collaboration
  • Partner with IT, Quality, Compliance, Medical Management, Provider Relations, and Member Services teams.
  • Participate in operational committees and quality improvement initiatives.
  • Assist with provider and internal staff education related to claims processes and regulatory requirements.
Education and Experience

Required

  • Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or related field.
  • 3–5 years of health plan claims operations, business analysis, or healthcare analytics experience.
  • Experience with Medicare Advantage, Medicaid, or managed care claims processing.
  • Strong analytical and reporting skills.

Preferred

  • Experience working with claims platforms (Facets, QNXT, HealthRules, or similar).
  • Experience supporting CMS audits and regulatory compliance activities.
  • Knowledge of encounter data reporting and MA organization requirements.
  • Lean Six Sigma or process improvement experience.
  • Knowledge of Medicare Advantage claims payment methodologies.
  • Understanding of claims adjudication and provider reimbursement concepts.
  • Advanced Excel and data analysis skills.
  • Ability to analyze large data sets and identify operational trends.
  • Strong verbal and written communication skills.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

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