SPE-Claims HC

Job description

Job Summary This role focuses on accurate processing and adjudication of health care claims using Qiclink and QNXT platforms within a work from home model. The specialist ensures timely resolution of medical claims adherence to policies and reduction of errors while collaborating with cross functional teams. The position supports better health outcomes by enabling efficient claim handling for members and providers. Responsibilities • Process health care claims in Qiclink and QNXT systems with consistent attention to detail and adherence to defined business rules for medical claim workflows • Review claim submissions for eligibility benefit coverage coding consistency and documentation completeness to ensure accurate adjudication outcomes • Apply claims adjudication rules and configuration guidelines to determine payment accuracy and appropriate benefit application for each claim • Validate provider member and plan data in Qiclink and QNXT to reduce rework minimize claim fallout and maintain high data quality standards • Investigate claim discrepancies and complex scenarios by analyzing system records historical claims and policy references to reach accurate resolution • Coordinate with operations configuration and support teams through virtual channels to clarify benefit designs policy interpretations and system updates impacting claim decisions • Monitor daily work queues prioritize assigned claims based on service level timelines and ensure consistent completion of volumes within expected turnaround times • Document claim decisions rationale and special handling notes clearly in the system to support downstream audit reporting and customer service inquiries • Identify recurring claim issues pattern trends and process gaps and propose improvements that can reduce errors and improve first pass resolution rates • Follow established quality standards internal controls and compliance guidelines to support regulatory requirements and organizational audit readiness • Support member and provider satisfaction by ensuring fair and timely claim outcomes that align with benefit policies and transparent processing practices • Collaborate with peers and supervisors in a remote setting to share knowledge clarify complex claim scenarios and maintain consistent adjudication practices across the team • Utilize available knowledge bases standard operating procedures and training materials to stay current on product changes and new claim handling requirements • Participate in calibration sessions feedback reviews and quality discussions to continuously improve personal accuracy and productivity in daily claims work • Assist in testing claim system enhancements in Qiclink and QNXT by executing sample scenarios and documenting observed issues for technical teams • Contribute to organizational goals by supporting efficient claim flows that reduce administrative burden and help members access timely health care benefits Qualifications • Possess two to four years of experience in health care claim processing with direct hands on exposure to Qiclink claim workflows and related functionalities • Demonstrate strong working knowledge of QNXT medical claim modules including claim entry pricing benefits application and payment determination logic • Exhibit proven experience in claim adjudication activities such as eligibility verification coordination of benefits and application of plan rules to diverse claim types • Show familiarity with health care claim domain concepts including member benefits provider networks coding structures and denial or adjustment scenarios • Apply clear analytical and numerical skills to interpret claim data identify anomalies and ensure that payment calculations align with policy expectations • Communicate effectively in a remote environment using written and verbal channels to clarify issues with colleagues and ensure consistent interpretation of claim guidelines • Manage work time independently within day shift schedules while maintaining productivity expectations and meeting assigned service level targets • Adapt to evolving claim policies product changes and system enhancements by embracing continuous learning and updating personal knowledge proactively • Maintain high ethical standards and a customer focused mindset to ensure that claim outcomes support organizational values and contribute to societal trust in health care systems Certifications Required Bsc Nursing with 2-3 years of Clinical experience