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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