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