Medical Claim Pricing Configuration Lead/SME, Remote

Title: Medical Claim Pricing Configuration Lead/SME

Other Acceptable Titles: NetworX Configuration SME; Pricing Configuration Lead

Location- Remote

Location : Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington (state), West Virginia, Wisconsin, Wyoming

References required (Manager)

Must Haves:

- Knowledge of NetworX Pricer and Optum Pricers is required. Qnxt strongly experience preferred.

- Great communication skills

- Strong SQL knowlege and ability to write own queries.

- Minimum of 8+ years experience in configuration/systems background.

- Strong Knowledge of Medical Claims processing, reimbursement methodologies, and related systems.

- Experience leading and managing teams

Pluses:

- QNXT

Day to Day:

• Improving our End-to-End Provider Contract execution. We have a workgroup focused on this work, but I need to supplement the work with a pricing expert with the intent to drive improvements quicker.
• Improving our unit operational processes and quality.
• Bring more pricing subject matter expertise to our migration work.

Including Official Job Description from Client

Job Title: Medical Claim Pricing Configuration Lead

Responsible for leading and managing the configuration of medical claim pricing and related systems, ensuring accuracy and efficiency in claim processing. Oversees processes for provider contracts, fee schedules, pricing rules and pricing software while ensuring compliance and smooth operations.

Key responsibilities include:

• Leading and Mentoring Teams: Responsible for leading a team of analysts and other configuration professionals, providing guidance, training, and direction, as well as motivating and evaluating performance.

• Configuring and Maintaining Systems: Responsible for configuring and maintaining systems, such as , and Optum Rate Manager to support accurate claims adjudication and provider reimbursement.

• Managing Provider Contracts: Work with the Configuration Manager or to configure, maintain, and ensure compliance with and .

• Ensuring Compliance: Ensure adherence to all relevant regulations, policies, and procedures related to medical claim pricing and configuration.

• Project Management: Manage project-related tasks by implementing, analyzing and improving systems and processes.

• Troubleshooting and Resolution: Identify, resolve, and prevent system errors or problems that can negatively impact the operational flow and efficiency of the claim adjudication processes.

Required Skills and Qualifications:

• 8+ years related professional experience; analytical, configuration, systems background.
• Strong Knowledge of Medical Claim Processing: A deep understanding of medical claim processing, reimbursement methodologies, and related systems.
• Technical Proficiency: Expertise in using configuration tools and systems like QNXT, NetworX Pricer and Optum Pricers, Optum Rate Manager.
• Leadership and Team Management: Experience leading and managing teams, motivating and directing individuals, and ensuring high performance.
• Project Management: Experience with project management methodologies, planning, implementation, and task completion
• Communication and Interpersonal Skills: Strong communication and interpersonal skills for interacting with various stakeholders.
• Analytical and Problem-Solving Skills: The ability to analyze complex data, identify issues, and implement effective solutions.
• Compliance: A strong understanding of compliance requirements and regulations.