Lead Analyst, Configuration Information Management (Claims Adjudication/ Networx/ QNXT)

DUTIES AND RESPONSIBILITIES 

• Interprets state, federal, contractual, benefit, and business requirements and translates them into clear configuration parameters. 

• Develops and maintains requirements documentation for coverage, reimbursement, claims processing, and related configuration requirements. 

• Monitors regulatory and industry updates to identify prospective and retrospective impacts to products, payments, compliance, and financial performance. 

• Coordinates benefit and requirement interpretation reviews, governance activities, approvals, and implementation timelines with health plans and corporate partners. 

• Communicates requirement decisions and changes to impacted stakeholders, ensuring end-to-end documentation, alignment, approval, and solution traceability. 

• Supports defect resolution, complaints, and claim or requirement interpretation issues for assigned components. 

• Develops standards and best practices that improve the consistency, quality, and efficiency of requirement interpretation and configuration across states and products. 

• Provides concise reporting and analysis on work status, regulatory changes, claim trends, appeals and grievances, compliance issues, and potential financial impacts. 

• Partners with Regional Product Managers, Configuration, Medical Management, Clinical Operations, and other teams to align filed benefits, coding, prior authorization, and system requirements. 

• Researches industry practices and recommends appropriate improvements for adoption. 

• Leads complex, cross-functional projects with limited direction while balancing multiple states, products, and requirement areas. 

• Builds effective relationships across Health Plans and Corporate functions and communicates clearly with employees at all organizational levels. 

• Synthesizes large, complex requirements into concise, actionable guidance. 

• Organizes and maintains regulatory information, including real-time policy and legislative changes. 

• Works independently in a remote, multi-time-zone environment; takes initiative to identify, communicate, and resolve issues. 

• Manages competing priorities and aggressive timelines while maintaining quality and accuracy. 

• Supports implementation and conversion activities for new and existing health plans, including application upgrades, releases, and test planning and execution. 

• Collaborates with health plans and corporate partners to define business objectives, document end-to-end requirements, and negotiate achievable completion dates. 

• Serves as a core system management subject matter expert and helps leadership establish standards, guidelines, and best practices. 

• Creates reporting tools and status communications for configuration updates, initiatives, and department-wide projects. 

• Trains and supports new and existing team members on configuration functionality, enhancements, and updates. 

• Manages fluctuating workloads and prioritizes assignments to meet department and user-community deadlines. 

REQUIRED QUALIFICATIONS 

• Five or more years of core system management, database maintenance, or analyst experience in managed care operations supporting Medicaid, Medicare, and/or Marketplace programs; an equivalent combination of education and experience may be considered. 

• Advanced experience with claims processing systems, including validating documentation for system updates and changes. 

• Strong analytical, critical-thinking, problem-solving, and attention-to-detail skills. 

• Ability to adapt to changing business needs while delivering accurate, high-quality work on time. 

• Effective written and verbal communication skills. 

• Proficiency with Microsoft Office, including intermediate to advanced Excel skills such as VLOOKUPs and PivotTables. 

• Familiarity with claims processing and administration systems such as QNXT and Networx Pricer.