QNXT Benefit Configuration Analyst

Position Overview

We are seeking an experienced QNXT Benefit Configuration Analyst to support the implementation, enhancement, and maintenance of benefit plans within the TriZetto QNXT platform. The ideal candidate will have extensive experience configuring commercial and/or government healthcare products, translating business requirements into system configurations, and collaborating with cross-functional teams to deliver high-quality healthcare solutions.

The candidate should possess strong knowledge of healthcare payer operations, benefit plan design, claims processing, SQL, and end-to-end testing.

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.