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.

Skills

Must have

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

Experience in Agile methodology and framework.

Other

Languages

English: C2 Proficient

Seniority

Senior

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