Project Description:

- You will be part of a team responsible for testing healthcare claims processing, benefits, pricing, and related workflows for a non-profit healthcare organization in the US.

- The role is focused on validating local claims processing within HealthRules Payer (HRP), including EDI transactions, Blue Card claims, and HRP-to-TPA workflows.

- You will collaborate closely with Product Owners, Business Analysts, Developers, and QA team members across the US, India and Mexico.

Responsibilities:

- Perform functional and end-to-end testing of healthcare claims processing within HealthRules Payer (HRP).

- Validate local claims processing workflows, business rules, benefits, pricing, and claims adjudication.

- Test and validate EDI 837 files and associated claims-processing workflows.

- Perform testing for Blue Card claims and related business scenarios.

- Validate HRP-to-TPA workflows, including upstream and downstream claims transactions.

- Create and execute test cases and test scenarios based on business and functional requirements.

- Analyze claims-processing results and identify inaccuracies or inconsistencies in business rules, configurations, pricing, and claim payments.

- Document, track, retest, and support resolution of defects identified during testing.

- Support investigation and resolution of production issues related to claims, benefits, and pricing configurations.

- Participate in business requirements and solution-review sessions to identify testing requirements and potential gaps.

- Collaborate with business and IT teams to validate system changes, enhancements, and configuration updates before production deployment.

- Provide subject-matter expertise regarding healthcare claims processing and HRP workflows.

- Maintain appropriate testing and system documentation.

Mandatory Skills Description:

- Mandatory Skills:

- - Healthcare Claims Processing

- - HealthRules Payer (HRP)

- - EDI 837

- - Blue Card





- - Healthcare Domain Knowledge

- - Claims Testing

Mandatory Skills Description:

- 4+ years of experience in healthcare claims processing, healthcare operations, or claims testing.

- Strong hands-on knowledge of local claims processing within HealthRules Payer (HRP).

- Hands-on experience working with and validating EDI 837 files.

- Experience with Blue Card claims processing and/or strong understanding of HRP-to-TPA workflows.

- Strong understanding of healthcare claims lifecycle, adjudication, benefits, pricing, and payment workflows.

- Good knowledge of healthcare and health-plan terminology.

- Understanding of relevant medical and industry-standard codes, including CPT, HCPCS, ICD-9/ICD-10, CDT, Revenue, and DRG codes.

- Experience creating and executing functional, integration, and end-to-end claims test scenarios.

- Ability to analyze claims-processing results, identify defects and configuration issues, and work with technical and business teams through resolution.

- Experience working with business requirements and translating them into comprehensive test scenarios.

- Working knowledge of Azure DevOps or similar test/defect management tools.

- Strong communication skills and ability to collaborate with business and technical stakeholders.

- Experience with BCBS Association requirements and Blue Card mandates.

- Experience with benefits and package pricing configuration in HealthRules.

- SQL knowledge for data validation and claims analysis.

- Experience troubleshooting production issues related to claims or benefit configurations.

- Previous experience supporting healthcare system migrations, integrations, or major HRP enhancements.

- Experience working with Third-Party Administrator (TPA) integrations and workflows.

Education:

- Bachelor's degree in Business Administration, Management Information Systems, Computer Science, or a related field, or equivalent relevant professional experience.

Nice-to-Have Skills Description:

- • Experience in Agile methodology and framework.

📌 Software Tester (México)
🏢 Luxoft
📍 México