Job Description

Position Purpose: This position is responsible for a variety of duties related to the provisioning, onboarding, and support of all claim environments and supporting interfaces.


  • Provide development support for migration of lines of business from MedMC onto QNXT
    • Interfaces to ancillary systems (eVips, EDM, Cotiviti/Verscend, Claims Workflow, AHCCCS Member Demographic DUGLess, etc.)
    • Support system configurations including required rule & edit customizations (QNXT Auto-Q: Dup edit, Max Unit edit, Conflicting Services edit, COB edit corrections, COB pricing, etc.)
    • Support the automated solution that imports (new, changes, terms) provider data (Demographic, Affiliations, etc.) from sources including MedMC, SalesForce, and soon to be eVips.
  • Provide mentorship and cross training to other team members
  • Support the EDI 834 application that imports and translates regulator sourced EDI 834s for all affected lines of businesses (SHCA enrollment types: ACC, RBHA, State-Only, Crisis, GOSUD; Mass Health Model B/A, Utah Medicaid, etc.) for import into the GlobalMembers database that feeds Care Radius, QNXT, Pharmacy Benefit Manager, etc.
  • Support the Claims Mergerator application that automates the separation and merging of acute claim files for import into MedMc as well as outbound EDI 837 files to AHCCCS.
  • Support the Claims Investigator solution, which obtains and stores EDI 837 file details into tables to support inventory reporting. This solution supports the full tracking of all claim file information on re-merged/outbound files.
  • Support and close all tickets from operations for enhancements and modifications to claims adjudication systems or related interfaces
  • Develop and maintain SSIS packages to import data from various 3rd party vendors and to export data in a variety of standard formats that meet both business and state contractual requirements
  • Identify opportunities for legacy package improvements, build out plan and execute on redesign
  • Create and maintain SQL databases, tables, views and other database objects
  • Document processes workflows, training materials and other standard IT documentation
  • Troubleshoot and fine tune stored procedures for optimal performance

Education / Experience / Other Requirements


This position requires a Bachelor’s degree in a Computer Science related field with additional exposure to health plan claiming environments, or an equivalent combination of education and experience sufficient to successfully perform the essential duties of this position.

Years of Experience:

Three years of experience in healthcare, analytics, statistical analysis (regression, KPIs, sampling, risk analysis), performance improvement or data and outcomes measurement; or an equivalent combination of education and experience sufficient to successfully perform the essential duties of this position is strongly preferred, or an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position.

  • At least five (5) years’ experience using T-SQL (SPROCS, Functions, Triggers, CTEs, Tuning, etc.)
  • At least five (5) years’ experience using Visual Studio .NET/C# solutions including, Business Intelligence projects (SSRS, SSIS, etc. - BIDS, SSDT, etc.)
  • At least five (5) years’ experience using Visual Studio .NET/C# solutions
  • Experience supporting Microsoft BizTalk configurations, orchestrations, and packages a plus
  • Experience supporting QNXT and AutoQ customizations and interfaces a plus
  • Experience supporting Business Intelligence projects (SSRS, SSIS, etc. - BIDS, SSDT, etc.) a plus
  • Experience supporting Cognizant QMU/CMU, Claim Test Pro, Encounter Data Management (EDM), Networx Pricer, Optum CES, 3M Pricer, Claims Workflow customizations a plus
  • Experience supporting Vistar eVips a plus
  • Experience supporting ClaimsXten™, ClaimCheck, Micro-Dyn, OnBase, Optum Claims Editing, Cotiviti's (Verscend) Claim Editing a plus
  • Experience with Team Foundation Server, RedGate, JAMS, GIT and Visio a plus

Specialized Knowledge:

The position requires a high attention to detail and ability to work under pressure, in conflict situations, and under strict deadlines. Additional skills and knowledge include:

  • Design develop, and deploy software solutions that address the needs of stakeholders and are consistent with HIPAA, industry, state and federal standards
  • Analyze and verify customer requirements for completeness, consistency, comprehensibility, feasibility, and conformity to standards
  • Utilize various technologies (MS BizTalk, MS SSIS, EdiDev, etc.) that support the development and maintenance of ETL solutions, which exchange data with external trading partners (Vendors, providers, and health care regulators, etc.) using a variety of proprietary and standardized interchange formats (ANSI X.12 EDI 837i,p,d, 834, 835, 278, 270/271, JSON, XML, CSV/Pipe, Tab, etc.)
  • Utilize Microsoft web based development technologies including ASP.NET (MVC 5/6 and/or Web Forms, C#/.NET Framework 4.52/4.6, AJAX, HTML 5/6, CSS3, JavaScript, JQuery 3, Bootstrap) to create integrated enterprise managed care applications and solutions
  • Query data from SQL Server 2008 R2 through 2017 Enterprise databases
  • Develop complex stored procedures, functions, dynamic SQL, CTEs, triggers, etc. in SQL Server T-SQL
  • Utilize MS Visual Studio and TFS in an agile team oriented development environment
  • Experienced with ETL best practices and technologies including Microsoft SQL Server Integration Services (SSIS)/Microsoft Data Transformation Services (DTS)
  • Knowledge of advanced relational database design concepts
  • Create ERDs, data dictionaries, process models, specifications, diagrams, and charts
  • Familiar with query tuning and with evaluating and configuring other DB performance tuning techniques through the use of Indexes, staged data, and other optimization methods
  • Adaptable to dynamically changing environments
  • Work cooperatively, positively, and collaboratively with interdisciplinary teams including business customers
  • Ability to produce under stressful situations
  • Ability to manage multiple tasks and prioritize work to adhere to deadlines and within identified time frames
  • Experienced and familiar with managed health care systems, processes, procedures, practices and measures (ex. member enrollments, services provided to members, member demographics, claims/encounters, prior authorizations, provider, quality, clinical, crisis, utilization metrics and meta data, etc.)
  • Familiar with ITIL Service Delivery and Lean Six Sigma best practices

Application Instructions

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