Job Description
Must Have Technical/Functional Skills
Strong SME knowledge in Healthcare Claims Processing lifecycle
Expertise in EDI formats 837 (P/I/D), 835, 834
Hands-on experience in Facets (Claims + Enrollment modules)
Proficiency in Azure DevOps (ADO) for QA tracking
Knowledge of HIPAA compliance and payer systems
8+ years of experience in Healthcare QA/Testing
4+ years of experience as Test Lead in Facets projects
Deep understanding of Claims Adjudication & Payment workflows
Experience in handling claims denials, adjustments, and reprocessing
Strong exposure to EDI claim and remittance transactions
Experience in mocking and validating EDI files (837/835/834)
Knowledge of ITS claims processing (SF, DF, RF)
Experience in Member Enrollment workflows (Medicaid, Medicare, ACA)
Understanding of Billing lifecycle for member enrollment
Hands-on experience with ADO Test Plans, Test Suites, and Defect tracking
Ability to perform data validation and reconciliation activities
Strong experience in functional and end-to-end testing
Familiarity with Agile/Scrum methodologies
Excellent stakeholder communication and coordination skills
Experience in risk identification, defect triage, and RCA
Roles & Responsibilities
Lead end-to-end testing for Claims, Enrollment, and Billing modules
Act as SME for Claims Processing and EDI transactions
Validate Facets Claims and Membership workflows
Design and execute test strategies, test plans, and test cases
Perform EDI validation (837, 835, 834) including mock data creation
Manage defect lifecycle, triage, and resolution tracking in ADO
Ensure HIPAA compliance in all testing activities
Validate ITS claims processing across SF, DF, RF flows
Drive quality metrics, reporting, and release sign-offs
Collaborate with business, development, and partner teams for E2E validation
Generic Managerial Skills, If any
Leading and Mentoring team members
Strong problem-solving and critical thinking
Ability to work with minimal supervision
Documentation and knowledge sharing
Excellent communication
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