QA / Healthcare Claims Specialist (Health Rules Payer)Location:Remote (Nearshore / US Time Zones)
Type:Contract / Full-TimeAbout the Role
We are looking for a detail-orientedHealthcare Claims QA Specialistto 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 withinHealth Rules 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 & Requirements
Core Expertise:Healthcare Claims Processing, Healthcare Operations, & Claims Testing (4+ years of experience).
System Knowledge:Strong hands-on experience withHealth Rules 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 Dev Ops(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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