QNXT Architect - Claims Processing & Adjudication

QNXT Architect – Claims Processing & AdjudicationRole Overview We are seeking aQNXT Architectto lead the design and optimization ofclaims processing and adjudication platformswithin complex healthcare payer environments. This role is responsible for architecting scalable, efficient, and compliant claims solutions that improveauto-adjudication rates, accuracy, and overall operational performance . The ideal candidate combines deepfunctional expertise in claims operationswith strongtechnical architecture capabilities , and has a proven track record of modernizing core administration platforms.Key Responsibilities Enterprise Claims Architecture Architect and optimize theend-to-end claims lifecycle , including intake, validation, pricing, adjudication, payment, and post-processing Design robust adjudication frameworks encompassing: Benefit plan configuration and accumulators Provider contract modeling and pricing logic Claims edits and business rules Lead solution design across QNXT environmentsAdjudication Strategy & Optimization Drive improvements inauto-adjudication and first-pass resolution rates Optimize claims processing through: Enhanced edit configuration (pre- and post-adjudication) Advanced pricing methodologies (fee-for-service, DRG, capitation, value-based models) Coordination of Benefits (COB) and complex claim scenarios Identify and remediateclaims leakage, denials, and payment inaccuraciesPlatform Configuration & Integration Oversee configuration and governance of: Benefits, eligibility, and accumulators Provider contracts, fee schedules, and reimbursement logic Lead integration design across: EDI transactions (837 claims, 835 remittances) Clearinghouses and provider systems Downstream finance and payment platforms Ensure data integrity and alignment across operational and reporting systemsModernization & Transformation Introduce automation and digital capabilities, includingRPA and AI-assisted adjudication Design for scalability, includingreal-time or near real-time claims adjudication Contribute to cloud and hybrid architecture strategiesGovernance & Leadership Partner with cross-functional stakeholders across Claims, Provider Relations, Finance, and IT Establish and enforcearchitecture standards, controls, and best practices Ensure compliance with regulatory requirements (e.g., HIPAA, CMS) Mentor and guide technical and functional teamsQualifications Required 8+ years of experience inhealthcare payer systems , with a focus on claims processing Deep expertise in: QNXT claims and adjudication architecture Strong understanding of: Claims lifecycle and adjudication logic Benefit design, provider reimbursement, and pricing models Experience with: EDI standards (837, 835) Data validation and analysis (e.g., SQL) System integration patterns (APIs, middleware)Preferred Experience leadingplatform modernization or migration initiatives Exposure to: Payment integrity and claims auditing solutions Value-based care and alternative payment models Familiarity with automation and workflow tools (e.g., RPA platforms) Cloud platform experience (AWS, Azure)