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NOTE: This is a 100% remote position. Selected candidates will be working on EST hours.

Job Title: Medical Claims Pricing Configuration Lead (NetworX SME)

Location: Fully Remote (Applicants must reside in one of the following states: AL, DE, FL, GA, ID, IN, KS, LA, ME, MD, MN, NE, NV, NH, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WA, WV, WI, WY)

This is an excellent opportunity for a pricing configuration leader who thrives on solving complex problems, enjoys working remotely, and brings deep subject matter expertise in healthcare reimbursement systems.

Overview:

Seeking a seasoned NetworX Configuration Subject Matter Expert to step into a leadership role overseeing the setup and optimization of pricing systems for medical claims. This fully remote opportunity requires a deep understanding of pricing configuration platforms-especially NetworX Pricer and Optum tools-as well as the operational know-how to streamline provider contract execution and claim accuracy.

What You'll Do:

• Lead Configuration Strategy: Direct a team of configuration analysts, providing coaching, performance feedback, and strategic leadership to optimize system functionality.
• Drive Pricing Improvements: Act as a key contributor in accelerating end-to-end enhancements in provider contract pricing. Collaborate across workgroups to elevate execution speed and process quality.
• Optimize Systems: Manage and maintain pricing tools such as QNXT, NetworX Pricer, and Optum Rate Manager to ensure claims are adjudicated accurately and efficiently.
• Manage Provider Contracts: Collaborate with project or configuration managers to configure and monitor provider contracts and fee schedules while ensuring they align with compliance requirements.
• Enhance Operational Processes: Identify inefficiencies in unit-level operations and implement refinements to improve turnaround time and data accuracy.
• Troubleshoot and Resolve: Proactively identify and fix system-level issues that affect claims processing and reimbursement accuracy.
• Ensure Regulatory Compliance: Uphold policies, regulatory requirements, and standard procedures across all configuration activities.

What We're Looking For:

• Experience: Minimum 8 years in healthcare systems/configuration, with hands-on experience in claim pricing and configuration workflows.
• Expertise in Pricing Platforms: Strong command of NetworX Pricer, Optum Pricers, and ideally QNXT.
• Healthcare Acumen: Solid foundation in medical claims processing, provider reimbursement strategies, and pricing methodologies.
• Leadership Skills: Proven ability to lead teams, manage performance, and drive results in high-stakes environments.
• Communication: Excellent verbal and written communication skills to effectively liaise with cross-functional stakeholders.
• Analytical Thinking: Strong problem-solving skills with the ability to evaluate complex issues and design actionable solutions.
• Compliance Knowledge: Deep familiarity with industry regulations and best practices for claims pricing and configuration.

Preferred Qualifications:

• Proficiency in QNXT or similar claims administration platforms
• Background in overseeing pricing elements during system migrations
• Experience managing quality improvement initiatives in claims operations

Interested candidates may submit their resumes online or call at 310-906-4780 for further information regarding the position.

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