Description

Key Responsibilities

* Analyze business requirements, functional specifications, user stories, configuration documents, and acceptance criteria.
* Develop comprehensive test plans, test scenarios, test cases, test data, and traceability matrices.
* Perform functional, integration, system, regression, end-to-end, smoke, and UAT support testing.
* Perform testing of HealthRules Payer (HRP) functionality across:
* Claims processing and adjudication
* Benefit configuration
* Products and plans
* Member enrollment and eligibility
* Provider configuration
* Provider contracts and reimbursement
* Billing
* Authorization
* Accumulators
* Deductibles, copays, coinsurance, and out-of-pocket maximums
* Validate professional and institutional claim processing.
* Verify claims through the complete adjudication lifecycle, including:
* Claim intake
* Validation
* Pricing
* Benefit determination
* Provider contract application
* Member liability
* Edits and pends
* Denials
* Payment
* Adjustments and reprocessing
* Validate HRP business rules and configuration against business requirements.
* Test different healthcare lines of business, including Commercial, Medicare, Medicaid, Medicare Advantage, and ACA/Exchange.
* Validate coordination of benefits (COB), duplicate claims, corrected claims, replacement claims, voids, adjustments, and retroactive eligibility scenarios.
* Validate benefit accumulators, including individual/family deductibles, embedded/non-embedded deductibles, coinsurance, copays, and maximum out-of-pocket amounts.

EDI / Healthcare Transaction Testing

Perform validation of HIPAA EDI transactions including:

* 837P / 837I – Professional and Institutional Claims
* 834 – Enrollment
* 835 – Claim Payment/Remittance
* 270/271 – Eligibility Inquiry/Response
* 276/277 – Claim Status
* 278 – Authorization/Referral
* 999 / TA1 – Acknowledgment transactions

Validate inbound and outbound transactions, data mapping, transformation, interface processing, error handling, reconciliation, and downstream processing.

Integration Testing

* Test integrations between HealthRules Payer and upstream/downstream applications.
* Validate real-time and batch interfaces.
* Test API, web service, file-based, and EDI integrations.
* Validate claims routed between HRP and external pricing, editing, payment integrity, provider, enrollment, authorization, and reporting platforms.
* Verify interface error handling, retries, reconciliation, and exception processing.
* Validate that appropriate transactions are routed to the correct processing platform based on defined business rules.

SQL & Data Validation

* Write SQL queries to validate backend data.
* Perform source-to-target and database validation.
* Validate member, provider, claim, benefit, authorization, contract, and payment data.
* Perform record-count, duplicate, null, transformation, and reconciliation testing.
* Investigate data discrepancies between HRP and integrated systems.
* Perform database-level validation for batch and interface processing.

Defect Management

* Identify, document, and track defects through resolution.
* Provide detailed defect documentation including test data, expected results, actual results, screenshots, SQL evidence, and reproduction steps.
* Participate in defect triage meetings with business analysts, developers, configuration teams, and business stakeholders.
* Perform defect retesting and regression testing.
* Track testing progress, defect trends, risks, dependencies, and release readiness.

Agile Responsibilities

* Participate in sprint planning, backlog refinement, daily stand-ups, defect triage, sprint reviews, and retrospectives.
* Review user stories and acceptance criteria for testability.
* Estimate QA effort for stories and releases.
* Maintain requirements-to-test-case traceability.
* Collaborate with Product Owners, Business Analysts, Developers, Configuration Analysts, and other QA team members.

Required Qualifications

* 5+ years of healthcare QA/testing experience.
* Strong hands-on experience with HealthEdge HealthRules Payer (HRP).
* Strong understanding of healthcare payer operations.
* Experience testing claims adjudication, benefits, enrollment, providers, contracts, and billing.
* Strong knowledge of Medicare, Medicaid, Commercial and/or ACA health plans.
* Experience with HIPAA EDI transactions such as 837, 834, 835, 270/271, 276/277, and 278.
* Strong SQL skills for backend/database validation.
* Experience with functional, integration, regression, end-to-end, and UAT testing.
* Experience with defect management and test management tools.
* Strong analytical and troubleshooting skills.
* Excellent verbal and written communication skills.

Preferred Skills

* Experience with HealthRules Designer, HealthRules Manager, HealthRules Connector, and HealthRules Answers.
* Experience validating HRP configuration changes and configuration migration between environments.
* Experience with healthcare claim pricing and payment integrity solutions.
* Understanding of CPT, HCPCS, ICD-10, DRG, revenue codes, modifiers, NDC, and provider reimbursement methodologies.
* API testing experience using Postman or similar tools.
* Experience with automation tools such as Selenium, Playwright, or similar frameworks.
* Experience with Jira, Azure DevOps, ALM/Quality Center, or similar tools.
* Experience working on QNXT, Facets, or other payer platforms is an advantage.

Key Technical Skills

HealthRules: HealthRules Payer (HRP), HealthRules Designer, HealthRules Manager, HealthRules Connector, HealthRules Answers
Healthcare: Claims, Benefits, Enrollment, Providers, Contracts, Billing, Authorization, Accumulators
EDI: 837P/I, 834, 835, 270/271, 276/277, 278, 999
Database: SQL, SQL Server/Oracle
Testing: Functional, Integration, Regression, System, E2E, UAT, Data Validation
Tools: Jira, Azure DevOps, ALM/Quality Center, Postman
Methodologies: Agile/Scrum, Waterfall

Key Skills

Education

Any Gradute