? QA / Healthcare Claims Specialist (HealthRules Payer)

- Location: Remote (Nearshore / US Time Zones)
- Type: Contract / Full-Time

About the Role

We are looking for a detail-oriented Healthcare Claims QA Specialist to join a collaborative integral team. You will be responsible for testing and validating healthcare claims processing, benefits, pricing, and related workflows for a US non-profit healthcare organization.

You’ll work closely with Product Owners, Business Analysts, and cross-functional teams across the US, India, and Mexico.

Key Responsibilities

- Perform functional, integration, and end-to-end testing of healthcare claims within HealthRules Payer (HRP).
- Validate local claims workflows, adjudication, business rules, pricing, benefits, and payment cycles.
- Test and validate EDI 837 files, Blue Card claims, and HRP-to-TPA upstream/downstream workflows.
- Analyze claims results, identify configuration discrepancies, track defects, and support troubleshooting/resolution.
- Translate business requirements into comprehensive test scenarios and collaborate on system changes before production deployment.





? Mandatory Skills & Requirements

- Core Expertise: Healthcare Claims Processing, Healthcare Operations, & Claims Testing (4+ years of experience).
- System Knowledge: Strong hands-on experience with HealthRules Payer (HRP).
- Standards & Files: Hands-on experience working with and validating EDI 837 files.
- Specialized Claims: Experience with Blue Card claims processing and/or strong understanding of HRP-to-TPA workflows.
- Domain Knowledge: Healthcare claims lifecycle, adjudication, benefits, pricing, and health-plan terminology.
- Medical Codes: Understanding of CPT, HCPCS, ICD-9/ICD-10, CDT, Revenue, and DRG codes.
- Execution & Tools: Experience creating/executing end-to-end claims test scenarios and working with Azure DevOps (or similar test/defect management tools).
- Collaboration: Strong communication skills to analyze issues and work with technical and business teams through resolution.
- Education: Bachelor’s degree in CS, MIS, Business Administration, or equivalent relevant experience.

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