QA / Healthcare Claims Specialist (HealthRules Payer) Location: Remote (Nearshore / US Time Zones)Type: Contract / Full-TimeAbout the RoleWe 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 ResponsibilitiesPerform 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 & RequirementsCore 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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