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 general 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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