Role & seniority: QA Analyst – Payment Integrity and Claims Repricing (mid-level to senior individual contributor)

Stack/tools: SQL for data validation; test case development; regression testing; traceability matrices; defect logging and documentation of pricing/calculation logic (CPT/HCPCS, DRG/APC, Medicare pricing)

Top 3 responsibilities

1. Claims repricing validation across provider contracts, fee schedules, CPT/HCPCS, DRG/APC logic, and Medicare-based pricing; verify allowed amounts, patient responsibility, and payer liability; test in-network vs out-of-network scenarios; validate multiple pricing methodologies

2. Functional and regression testing: create and execute test cases, perform regression tests, validate edge cases

3. Data validation and documentation: write SQL queries to validate financial fields, compare expected vs actual amounts, identify duplicates; document pricing discrepancies with calculations and maintain traceability; log defects with reproducible steps and impact

Must-have skills

• Strong SQL for data validation and reconciliation

• Experience designing and executing QA tests for pricing/claims

• Understanding of healthcare pricing concepts (CPT/HCPCS, DRG/APC, Medicare-based pricing)

• Ability to verify allowed amounts, patient responsibility, and payer liability

• Defect logging and traceability matrix maintenance

Nice-to-haves

• Prior work in payment integrity or healthcare claims testing

• Familiarity with pr