Requirement Healthcare EDI 837 Manual Tester with Facets Experience
We are looking for an experienced Healthcare EDI Manual Tester / QA Analyst with strong hands-on experience in 837 Professional (837P) and Institutional (837I) claims and TriZetto Facets.
Required Skills
* 5+ years of experience in Healthcare IT / Claims / EDI testing.
* Strong hands-on experience with manual testing of 837P and 837I healthcare claims.
* Strong understanding of HIPAA X12 5010 claim transactions and EDI file structures.
* Ability to manually analyze and validate 837 loops, segments, elements, qualifiers, and values.
* Experience validating key claim information including:
* Billing, Rendering, Referring and Service Facility providers
* Subscriber and Patient information
* Member IDs
* Diagnosis codes
* CPT/HCPCS and procedure codes
* Revenue codes
* Place of Service
* Dates of service
* Claim and service-line charges
* COB and coordination of benefits information
* Strong hands-on experience with TriZetto Facets, particularly Facets Claims.
* Ability to validate incoming 837 claim data against the corresponding claim information loaded into Facets.
* Experience testing Professional and Institutional claim adjudication in Facets.
* Ability to create and execute manual test cases and test scenarios covering positive, negative, boundary and exception conditions.
* Experience troubleshooting claim failures by tracing data from the 837 EDI file through Facets claim processing/adjudication.
* Understanding of 999 and 277CA acknowledgments, including identification and analysis of rejected claims.
* Knowledge of 835 remittance transactions and ability to perform claim-to-remittance validation is highly desirable.
* Experience with Medicaid and/or Medicare claims processing is preferred.
* Good understanding of the overall healthcare claims lifecycle: 837 submission EDI validation Facets claim load adjudication payment/denial 835.
* Ability to write and execute SQL queries for backend/database validation is preferred.
* Experience working with payer-specific EDI companion guides, business rules and mapping requirements.
* Strong analytical and troubleshooting skills with the ability to identify whether an issue originates from the source 837, EDI translation/mapping, Facets configuration, or claim adjudication logic.
Primary Responsibilities
The resource will be responsible for performing end-to-end manual testing of healthcare 837 claims, validating EDI data against Facets, executing different claim scenarios, identifying defects and working with EDI, development, configuration and business teams to troubleshoot issues.
The candidate should be capable of taking a raw 837P/837I file, understanding the claim at the loop/segment/element level, determining the expected processing outcome, locating the resulting claim in Facets, and validating that the claim was loaded and adjudicated correctly.
Key Search Keywords
Healthcare EDI QA, 837 Manual Tester, 837P, 837I, X12 5010, Facets Tester, TriZetto Facets, Facets Claims, Claims Adjudication, EDI Testing, 999, 277CA, 835, HIPAA EDI, SQL, Medicare, Medicaid, Professional Claims, Institutional Claims
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