? 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 general 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 r
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