Role Overview
Responsible for test execution and validation across real-time pharmacy claims processing and adjudication systems.
Collaborate with business SMEs, product owners, and engineering teams to ensure quality and compliance.
Key Responsibilities:
Analyze user needs and prepare test scenarios and test cases using Agile methodology
Create and maintain test artifacts for release testing (test cases, test data, execution results)
Participate in execution of release testing (SIT, regression, E2E)
Support test leads in meeting timelines and schedules for testing efforts
Execute test cases based on defined test plans and acceptance criteria
Follow and adhere to established QA standards, processes, and procedures
Communicate effectively with team members, stakeholders, and vendors as needed
Assist in test environment setup and validation activities
Follow standard testing methodologies and organizational QA frameworks
Participate in release-specific testing activities and coordination
Update and execute test cases and test data as per requirements
Participate in test case reviews, walkthroughs, and peer reviews
Support release validation and deployment verification activities
Contribute to lessons learned and continuous improvement initiatives
Identify, log, and track defects through to closure
Work with BA/Dev teams to clarify requirements and resolve issues
Perform basic troubleshooting and issue analysis
Work both independently and collaboratively in a team environment
Experience Required:
Minimum of 4+ years of QA experience with PBM / pharmacy claims domain knowledge
Experience in writing SQL queries for data validation
Ability to design and execute test cases, test scenarios, and test data
Hands-on experience in validating end-to-end pharmacy claims lifecycle, including:
o Member eligibility and benefit verification
o Pharmacy/provider validation (NPI, NCPDP ID)
o Real-time POS claims adjudication
o Pricing logic (AWP, MAC, ingredient cost, dispensing fee, copay, accumulators)
Experience in testing scenarios involving:
o Coordination of Benefits (COB) / Other Payer
o Prior Authorization (PA)
o Formulary and benefit plan rules
o Specialty and retail pharmacy claims
Understanding of NCPDP standards (D.0; exposure to F6 preferred)
Ability to interpret business and technical requirements for testing Agile/Waterfall models
Valuable communication skills to report test results and defects clearly
Experience in web services/API testing using Postman or SoapUI
Basic knowledge of automation tools and testing practices
Strong interpersonal skills and ability to work with cross-functional teams