QA / Healthcare Claims Specialist (HealthRules Payer)Location:Remote (Nearshore / US Time Zones)Type:Contract / Full-TimeAbout the RoleWe are looking for a detail-orientedHealthcare Claims QA Specialistto 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 ResponsibilitiesPerform functional, integration, and end-to-end testing of healthcare claims withinHealthRules Payer (HRP).
Validate local claims workflows, adjudication, business rules, pricing, benefits, and payment cycles.Test and validateEDI 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 & RequirementsCore Expertise:Healthcare Claims Processing, Healthcare Operations, & Claims Testing (4+ years of experience).
System Knowledge:Strong hands-on experience withHealthRules Payer (HRP).
Standards & Files:Hands-on experience working with and validatingEDI 837 files.Specialized Claims:Experience withBlue Cardclaims 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 withAzure 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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