Medicaid QNXT Provider

We are seeking an experienced Medicaid QNXT Provider Contract Setup & Testing Specialist with expertise in provider contract configuration, reimbursement methodologies, and functional testing within the healthcare payer domain.

The ideal candidate will have hands-on experience setting up and validating provider contracts in the QNXT platform, testing contract configurations, validating fee schedules and reimbursement rates, and ensuring accurate claims adjudication based on contractual terms.

Candidates with strong Medicaid provider contracting and QNXT Subject Matter Expert (SME) experience will also be considered, even if their primary background is not in formal QA testing.

Key Responsibilities:

- Configure and maintain provider contracts and agreements within the QNXT platform.
- Review provider contract terms and translate them into appropriate system configurations.
- Validate reimbursement rates, fee schedules, payment methodologies, and contract effective dates.
- Perform functional testing of provider contract setups and configuration changes.
- Execute test scenarios to verify accurate claims pricing and adjudication against contracted rates.
- Validate provider-specific, service-specific, and network-specific contract requirements.
- Prepare test cases, test scripts, test data, and test execution documentation.
- Identify, document, track, and support resolution of defects related to contract configuration and claims processing.
- Collaborate with provider contracting, claims operations, configuration, business, and QA teams.
- Support UAT, regression testing, implementation validation, and production issue investigation.
- Serve as an SME for Medicaid provider contract configuration, reimbursement rules, and claims validation, as applicable.

Required Skills:
- Strong knowledge of the US healthcare payer domain, particularly Medicaid and Medicaid Managed Care.
- Hands-on experience with QNXT / TriZetto QNXT.
- Experience in provider contract setup, configuration, or contract validation.
- Knowledge of provider reimbursement, fee schedules, and claims adjudication.
- Experience with functional testing, UAT, or claims testing.
- Ability to analyze provider contract terms and validate system behavior against business requirements.
- Strong analytical, troubleshooting, documentation, and communication skills.

Preferred Qualifications:

- Experience with Medicaid managed care plans.
- Experience with provider reimbursement methodologies, including fee-for-service and contracted rates.
- Knowledge of claims processing, pricing, and adjudication workflows.
- Experience with defect management and regression testing.
- Experience working with provider data, contract configuration tables, or related healthcare systems.
- Strong SME experience in provider contracting and QNXT, even without extensive formal QA experience.