SME – Qnxt

Job Summary:
We are seeking an experienced Subject Matter Expert (SME) with hands-on operational expertise in key business functions such as claim routing/queues, enrollment & billing exception handling, and benefit/provider pricing configuration. The ideal candidate will provide valuable insight into optimizing operational processes, particularly for a health plan with approximately 165,000 members. While prior experience with QNXT is a plus, the focus is on understanding the operational workflows and best practices within these areas to help improve efficiency and ensure optimal setup.

Responsibilities:

• Evaluate and advise on the operational processes related to claim routing, enrollment & billing exception handling, and benefit/provider pricing configuration.
• Leverage expertise in business functions to optimize workflows and system configurations, ensuring effective and efficient handling of claims, enrollments, and billing processes.
• Work closely with the internal team to provide recommendations on operational improvements based on industry best practices.
• Guide the setup of business processes for a health plan serving 165,000 members, ensuring scalability and operational excellence.

Qualifications:

• Proven operational experience in the areas of claim routing/queues, enrollment & billing exception handling, and benefit/provider pricing configuration.
• Familiarity with QNXT or similar systems (system knowledge is secondary to operational expertise).
• Strong understanding of health plan operations and business functions, with a focus on process optimization.
• Working in a QNXT / NetworX environment.  Look for someone with deep configuration and claim setup experience. 
• Ability to work collaboratively with internal teams to design, improve, and implement operational processes.
• Excellent problem-solving and analytical skills.