Project Description:

nYou 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.

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nThe role is focused on validating local claims processing within HealthRules Payer (HRP), including EDI transactions, Blue Card claims, and HRP-to-TPA workflows.

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nYou will collaborate closely with Product Owners, Business Analysts, Developers, and QA team members across the US, India and Mexico.

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nResponsibilities:

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nPerform functional and end-to-end testing of healthcare claims processing within HealthRules Payer (HRP).

nValidate local claims processing workflows, business rules, benefits, pricing, and claims adjudication.

nTest and validate EDI 837 files and associated claims-processing workflows.

nPerform testing for Blue Card claims and related business scenarios.

nValidate HRP-to-TPA workflows, including upstream and downstream claims transactions.

nCreate and execute test cases and test scenarios based on business and functional requirements.

nAnalyze claims-processing results and identify inaccuracies or inconsistencies in business rules, configurations, pricing, and claim payments.

nDocument, track, retest, and support resolution of defects identified during testing.

nSupport investigation and resolution of production issues related to claims, perks, and pricing configurations.

nParticipate in business requirements and solution-review sessions to identify testing requirements and potential gaps.

nCollaborate with business and IT teams to validate system changes, enhancements, and configuration updates before production deployment.

nProvide subject-matter expertise regarding healthcare claims processing and HRP workflows.

nMaintain appropriate testing and system documentation.

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nMandatory Skills:

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n- Healthcare Claims Processing

n- HealthRules Payer (HRP)

n- EDI 837

n- Blue Card

n- Healthcare Domain Knowledge

n- Claims Testing

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nMandatory Skills Description:

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n4+ years of experience in healthcare claims processing, healthcare operations, or claims testing.

nStrong hands-on knowledge of local claims processing within HealthRules Payer (HRP).

nHands-on experience working with and validating EDI 837 files.

nExperience with Blue Card claims processing and/or strong understanding of HRP-to-TPA workflows.

nStrong understanding of healthcare claims lifecycle, adjudication, benefits, pricing, and payment workflows.

nGood knowledge of healthcare and health-plan terminology.

nUnderstanding of relevant medical and industry-standard codes, including CPT, HCPCS, ICD-9/ICD-10, CDT, Revenue, and DRG codes.

nExperience creating and executing functional, integration, and end-to-end claims test scenarios.

nAbility to analyze claims-processing results, identify defects and configuration issues, and work with technical and business teams through resolution.

nExperience working with business requirements and translating them into comprehensive test scenarios.

nWorking knowledge of Azure DevOps or similar test/defect management tools.

nStrong communication skills and ability to collaborate with business and technical stakeholders.

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nExperience with BCBS Association requirements and Blue Card mandates.

nExperience with benefits and package pricing configuration in HealthRules.

nSQL knowledge for data validation and claims analysis.

nExperience troubleshooting production issues related to claims or benefit configurations.

nPrevious experience supporting healthcare system migrations, integrations, or major HRP enhancements.

nExperience working with Third-Party Administrator (TPA) integrations and workflows.

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nEducation:

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nBachelor's degree in Business Administration, Management Information Systems, Computer Science, or a related field, or equivalent relevant professional experience.

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nNice-to-Have Skills Description:

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nExperience in Agile methodology and framework.

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nLanguages:

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nEnglish: C2 Proficient

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