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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