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4+ years of experience in healthcare claims processing, healthcare operations, or claims testing.
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Strong hands-on knowledge of local claims processing within HealthRules Payer (HRP).
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Hands-on experience working with and validating EDI 837 files.
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Experience with Blue Card claims processing and/or strong understanding of HRP-to-TPA workflows.
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Strong understanding of healthcare claims lifecycle, adjudication, benefits, pricing, and payment workflows.
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Good knowledge of healthcare and health-plan terminology.
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Understanding of relevant medical and industry-standard codes, including CPT, HCPCS, ICD-9/ICD-10, CDT, Revenue, and DRG codes.
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Experience creating and executing functional, integration, and end-to-end claims test scenarios.
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Ability to analyze claims-processing results, identify defects and configuration issues, and work with technical and business teams through resolution.
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Experience working with business requirements and translating them into comprehensive test scenarios.
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Working knowledge of Azure DevOps or similar test/defect management tools.
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Strong communication skills and ability to collaborate with business and technical stakeholders.
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Experience with Association requirements and Blue Card mandates.
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Experience with benefits and package pricing configuration in HealthRules.
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SQL knowledge for data validation and claims analysis.
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Experience troubleshooting production issues related to claims or benefit configurations.
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Previous experience supporting healthcare system migrations, integrations, or major HRP enhancements.
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Experience working with Third-Party Administrator (TPA) integrations and workflows.