Health and Benefits Claims
Luxoft Mexico
- Project Description:
- You will be part of a team responsible for testing healthcare claims processing, benefits, pricing, and related workflows for a non-profit healthcare organization in the US.
- The role is focused on validating local claims processing within HealthRules Payer (HRP), including EDI transactions, Blue Card claims, and HRP-to-TPA workflows.
- You will collaborate closely with Product Owners, Business Analysts, Developers, and QA team members across the US, India and Mexico.
- Responsibilities:
- Perform functional and end-to-end testing of healthcare claims processing within HealthRules Payer (HRP).
- Validate local claims processing workflows, business rules, benefits, pricing, and claims adjudication.
- Test and validate EDI 837 files and associated claims-processing workflows.
- Perform testing for Blue Card claims and related business scenarios.
- Validate HRP-to-TPA workflows, including upstream and downstream claims transactions.
- Create and execute test cases and test scenarios based on business and functional requirements.
- Analyze claims-processing results and identify inaccuracies or inconsistencies in business rules, configurations, pricing, and claim payments.
- Document, track, retest, and support resolution of defects identified during testing.
- Support investigation and resolution of production issues related to claims, benefits, and pricing configurations.
- Participate in business requirements and solution-review sessions to identify testing requirements and potential gaps.
- Collaborate with business and IT teams to validate system changes, enhancements, and configuration updates before production deployment.
- Provide subject-matter expertise regarding healthcare claims processing and HRP workflows.
- Maintain appropriate testing and system documentation.
- Mandatory Skills Description:
- Mandatory Skills:
- - Healthcare Claims Processing
- - HealthRules Payer (HRP)
- - EDI 837
- - Blue Card
- - Healthcare Domain Knowledge
- - Claims Testing
- Mandatory Skills Description:
- 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 BCBS 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.
- Education:
- Bachelor's degree in Business Administration, Management Information Systems, Computer Science, or a related field, or equivalent relevant professional experience.
Vacante publicada el 1 día atrás
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