Full Description

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.

Candidate should have strong health care domain experience and should have good knowledge of Medicaid and Medicare. Candidate should have hands-on experience on claims processing and Adjudication processes. Must have good experience in Reference code/data sets required in Claims adjudication. Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems. Should be able to run queries and perform basic system analysis, RCA etc., 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 Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.

In depth understanding of Claims and Claims lifecycle

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

Claim Types

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

Claim Formats

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

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