QNXT Benefit Configuration Analyst

Roles and Responsibilities

• Configure and maintain benefit plans within the QNXT platform based on business and regulatory requirements. 
• Configure Service Groups, Restriction Groups, Copay Groups, Coinsurance, Deductibles, Out-of-Pocket Maximums (MOOP), Accumulators, Visit Limits, Authorization Rules, and Benefit Limits. 
• Configure benefits for Commercial, Medicare Advantage, Medicaid, Exchange, PPO, HMO, POS, EPO, and ASO products. 
• Analyze business requirements and translate them into detailed configuration specifications. 
• Collaborate with Business Analysts, Product Owners, Configuration Analysts, Developers, QA, and Business Stakeholders. 
• Perform impact analysis for new benefit changes, regulatory updates, and annual benefit plan implementations. 
• Support annual benefit rollovers and Open Enrollment implementations. 
• Validate benefit configurations using the QNXT Claims module to ensure claims adjudicate correctly. 
• Develop configuration documentation, design documents, mapping documents, and implementation guides. 
• Troubleshoot benefit configuration issues and identify root causes. 
• Support production incidents and resolve benefit configuration defects. 
• Participate in requirements gathering sessions, JAD sessions, backlog grooming, sprint planning, and release planning. 
• Work closely with QA teams during SIT, UAT, and regression testing. 
• Perform SQL queries to validate configuration data, troubleshoot issues, and analyze claim outcomes. 
• Participate in release deployments and post-production validation activities. 
• Collaborate with downstream teams supporting Claims, Enrollment, Provider, Finance, EDI, and Customer Service. 
• Maintain configuration version control using QCS, CMT, or other migration tools. 
• Ensure compliance with CMS, State Medicaid, and Commercial regulatory requirements. 

Required Qualifications

• 5+ years of Healthcare Payer experience. 
• 5+ years of hands-on TriZetto QNXT Benefit Configuration experience. 
• Strong understanding of healthcare benefit design and claims adjudication. 
• Experience configuring: 
  • Service Groups 
  • Restriction Groups 
  • Copay Groups 
  • Coinsurance 
  • Deductibles 
  • Accumulators 
  • MOOP 
  • Visit Limits 
  • Prior Authorization Rules 
  • In-Network / Out-of-Network Benefits 
• Experience with Commercial, Medicare, and Medicaid benefit plans. 
• Strong SQL skills including: 
• Experience troubleshooting claims adjudication issues. 
• Experience validating benefit configurations using test claims. 
• Ability to read and interpret business requirements and technical documentation. 
• Strong analytical and problem-solving skills. 
• Excellent communication and stakeholder management skills. 

Preferred Qualifications

• Experience with QCS (QNXT Configuration Studio). 
• Experience with CMT (Configuration Migration Tool). 
• Experience supporting annual benefit implementations. 
• Experience with Medicare Advantage and Medicaid Managed Care plans. 
• Experience with CMS regulations. 
• Experience working in Agile/Scrum environments. 
• Experience using Jira, Azure DevOps, or Rally. 
• Experience supporting large healthcare payer organizations. 

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