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 resol
📌 Healthcare NSA Analyst (México)
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