Job Description
Project Description:
n
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.
n
n
The role is focused on validating local claims processing within Health Rules Payer (HRP), including EDI transactions, Blue Card claims, and HRP-to-TPA workflows.
n
n
You will collaborate closely with Product Owners, Business Analysts, Developers, and QA team members across the US, India and Mexico.
n
n
Responsibilities:
n
n
Perform functional and end-to-end testing of healthcare claims processing within Health Rules Payer (HRP).
n
Validate local claims processing workflows, business rules, benefits, pricing, and claims adjudication.
n
Test and validate EDI 837 files and associated claims-processing workflows.
n
Perform testing for Blue Card claims and related business scenarios.
n
Validate HRP-to-TPA workflows, including upstream and downstream claims transactions.
n
Create and execute test cases and test scenarios based on business and functional requirements.
n
Analyze claims-processing results and identify inaccuracies or inconsistencies in business rules, configurations, pricing, and claim payments.
n
Document, track, retest, and support resolution of defects identified during testing.
n
Support investigation and resolution of production issues related to claims, benefits, and pricing configurations.
n
Participate in business requirements and solution-review sessions to identify testing requirements and potential gaps.
n
Collaborate with business and IT teams to validate system changes, enhancements, and configuration updates before production deployment.
n
Provide subject-matter expertise regarding healthcare claims processing and HRP workflows.
n
Maintain appropriate testing and system documentation.
n
n
Mandatory Skills:
n
n
- Healthcare Claims Processing
n
- Health Rules Payer (HRP)
n
- EDI 837
n
- Blue Card
n
- Healthcare Domain Knowledge
n
- Claims Testing
n
n
Mandatory Skills Description:
n
n
4+ years of experience in healthcare claims processing, healthcare operations, or claims testing.
n
Strong hands-on knowledge of local claims processing within Health Rules Payer (HRP).
n
Hands-on experience working with and validating EDI 837 files.
n
Experience with Blue Card claims processing and/or strong understanding of HRP-to-TPA workflows.
n
Strong understanding of healthcare claims lifecycle, adjudication, benefits, pricing, and payment workflows.
n
Good knowledge of healthcare and health-plan terminology.
n
Understanding of relevant medical and industry-standard codes, including CPT, HCPCS, ICD-9/ICD-10, CDT, Revenue, and DRG codes.
n
Experience creating and executing functional, integration, and end-to-end claims test scenarios.
n
Ability to analyze claims-processing results, identify defects and configuration issues, and work with technical and business teams through resolution.
n
Experience working with business requirements and translating them into comprehensive test scenarios.
n
Working knowledge of Azure Dev Ops or similar test/defect management tools.
n
Solid communication skills and ability to collaborate with business and technical stakeholders.
n
n
Experience with BCBS Association requirements and Blue Card mandates.
n
Experience with benefits and package pricing configuration in Health Rules.
n
SQL knowledge for data validation and claims analysis.
n
Experience troubleshooting production issues related to claims or benefit configurations.
n
Previous experience supporting healthcare system migrations, integrations, or major HRP enhancements.
n
Experience working with Third-Party Administrator (TPA) integrations and workflows.
n
n
Education:
n
n
Bachelor's degree in Business Administration, Management Information Systems, Computer Science, or a related field, or equivalent relevant professional experience.
n
n
Nice-to-Have Skills Description:
n
n
Experience in Agile methodology and framework.
n
n
Languages:
n
n
English: C2 Proficient
n
📌 Healthcare NSA Analyst (India)
🏢 Luxoft
📍 India