Our client, a IT Services and Consulting company, is looking for a QNXT Medical Claims Processor (Healthcare BPO) for their Phoenix, AZ location.
Responsibilities:
Review incoming medical claims on the QNXT platform and validate member details provider information and policy coverage to ensure accurate claim setup and processing
Process claims for medical services by applying payer rules benefit plans and contract terms to support accurate adjudication and payment decisions
Verify coding consistency for diagnoses procedures and modifiers using provided references to minimize claim errors denials and rework -Identify discrepancies or missing information in claim submissions and coordinate with internal teams to obtain clarifications and ensure timely resolution
Apply established business rules service level agreements and compliance guidelines during claim evaluation to maintain regulatory adherence and client satisfaction
Monitor daily claim queues within the workflow system prioritize tasks based on urgency and volume and complete assignments within defined turnaround times
Perform quality checks on processed claims using predefined audit checklists to detect defects implement corrective actions and support continuous improvement
Document all actions taken on claims in the system with clear concise and audit ready notes to maintain traceability and support future reviews
Collaborate with quality and training teams by sharing recurring issues or knowledge gaps observed in claims to help refine process documentation and training content
Respond to queries from internal stakeholders regarding claim status policy interpretation or processing logic while maintaining a professional and customer focused approach
Contribute to process improvement ideas by highlighting patterns in denials rework or system defects that impact productivity and suggesting practical solutions
Adhere to day shift schedules work from office guidelines and security protocols to maintain data confidentiality and a stable operational environment without travel requirements
Support team performance goals by maintaining personal productivity accuracy and attendance standards thereby contributing to the overall success of client healthcare operations and member satisfaction
Requirements:
Demonstrate hands on experience or training in QNXT claims processing for medical lines of business including familiarity with core claim adjudication workflows and navigation
Possess foundational knowledge of health insurance concepts such as eligibility benefits copay coinsurance deductibles and coordination of benefits to interpret claim scenarios effectively
Show understanding of medical billing components including procedure codes diagnosis codes and basic utilization management indicators sufficient for accurate data validation
Bring experience from BPO healthcare or back office operations where processing accuracy volume handling and adherence to service targets were critical performance measures
Exhibit strong analytical and problem solving skills to investigate claim issues identify root causes and apply appropriate resolutions without extensive supervision
Demonstrate proficiency in using office productivity tools and workflow applications to manage queues update records and communicate with stakeholders in a structured manner Communicate clearly in spoken and written form to document claim actions escalate issues and collaborate with team members and supervisors in a professional setting
Display flexibility to adapt to updated payer rules process changes and system enhancements with a willingness to learn and participate in refresher trainings as required
Prefer candidates who have exposure to quality frameworks or metrics driven environments where defect rates turnaround time and customer satisfaction were actively monitored
Prefer candidates who show strong attention to detail time management discipline and an ethical approach to handling sensitive health information in a work from office setting
Preferred certifications in healthcare such as Certified Professional Coder CPC or equivalent medical claims processing credentials.