Claims Tester

Job: Claims Tester

Location: Remote(USA)

Claims Tester:

Responsible for claims testing for MMIS health care projects. Drive the test strategy and process, domain knowledge, perform analysis of business requirements, designs and develops test plans, ensures quality process, coordinates with customers on delivery and deployments. Works in team environment and provides testing guidance throughout the entire life cycle. Responsible to meet customer expectations, troubleshoot problems in the application and assisting customers in implementation decisions.

1. Candidate should have strong health care domain experience and should have good knowledge of Medicaid and Medicare.
2. Candidate should have hands-on experience on claims processing and Adjudication processes.
3. Must have good experience in Reference code/data sets required in Claims adjudication.
4. Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
5. Should be able to run queries and perform basic system analysis, RCA etc.,
6. Should work closely with the client and development team during the stages of development, and conduct demos at completion of milestone, track and close feedback from such demos
7. Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks
8. Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
9. In depth understanding of Claims and Claims lifecycle:

• Member
• Provider
• Claim submission Paper and EDI X12
• Adjudication
• Payment Cycle (Finance)
• Reporting

1. Claim Types:

• Professional
• Dental
• Institutional
• Pharmacy
• Encounters and Capitation

11. Claim Formats:

• EDI X12 formats like 837P/I/D
• X12 formats 835, 834, 270/271, 276/277

12. Claim System:

• Familiarity with systems like CMdS, GHS, Facets and etc

Testing knowledge and E2E Testing:

• Validate the entire flow from claim intake to payment and reporting.
• Interface testing - Test integration points between systems
• Design test case based on business rules, coverage policies, and system configurations.
• Familiarity with test management tools like ADO, JIRA,
• Interface/API testing tools like Postman

Technical Skills

• SQL: To validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan).
• EDI Tools: Validating X12 files.
• Interface Testing: Understanding how data flows between systems and formats and use tools like postman

Preferred skills:

• Minimum of 5+ years of experience in health care experience especially in MMIS domain.
• Capability to think out-of-the-box to create new solutions as needed.
• Ability to validate Test scenarios and test plans, test data.
• Should be able to Review requirements, documentation and create Requirements Traceability matrix (RTM)
• Should have excellent communication (written and spoken ) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units.
• Ability to assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product.
• Ability to drive and share the requirements with Technical and Architects regarding product features to be implemented.
• Test Planning & Reporting: Create test plans, test summary reports, and traceability matrices.
• Communication: Collaborate with cross-functional teams including developers, SME s and BA s