Information Technology_USA - USA_Analyst

Job Summary

We are seeking a highly experienced Senior Healthcare NASCO Claims Domain Specialist / Claims UAT Testing Lead to lead end-to-end claims validation and testing initiatives for US healthcare insurance applications.

The ideal candidate will have deep hands-on expertise in NASCO claims processing, healthcare payer operations, claims adjudication, and UAT/testing. This role will serve as the primary onsite domain SME, working closely with business stakeholders, Product Owners, operations teams, development teams, QA teams, and offshore UAT/CoE teams.

The candidate should be comfortable providing domain leadership, defining testing strategy, driving UAT execution, managing defects, and mentoring testing teams.

Key Responsibilities

NASCO & Healthcare Claims Domain Leadership

• Serve as the primary SME for end-to-end NASCO claims processing.
• Provide expertise across professional, institutional, and pharmacy claims.
• Validate claims lifecycle, adjudication rules, payer configurations, benefit plans, and provider contracts.
• Analyze complex healthcare business rules and translate them into system and testing requirements.
• Identify domain risks, functional gaps, and improvement opportunities within claims workflows.
• Ensure claims processing aligns with applicable CMS, HIPAA, Medicare, Medicaid, and commercial health plan requirements.

Testing & UAT Leadership

• Define and drive the overall NASCO claims testing strategy, scope, coverage, and execution plan.
• Lead functional, system, integration, regression, and User Acceptance Testing (UAT) activities.
• Create, review, and approve test plans, test scenarios, test cases, and test data.
• Ensure comprehensive testing of:
  • Claims adjudication logic
  • Pricing and repricing
  • Deductibles and accumulators
  • Maximum Out-of-Pocket (MOOP)
  • Coordination of Benefits (COB)
  • Subrogation
  • Authorizations
  • Claims edits and exceptions
  • Provider and benefit configurations
• Lead UAT planning, business readiness, execution, and sign-off.
• Provide go/no-go recommendations based on testing results and release readiness.

EDI & Claims Validation

• Strong understanding of healthcare EDI transactions, including:
  • 837 – Healthcare Claims
  • 835 – Claims Payment/Remittance
  • 270/271 – Eligibility Inquiry and Response
• Validate end-to-end claims data flow and ensure accuracy across upstream and downstream systems.
• Perform or guide backend/data validation; SQL knowledge is an advantage.

Defect Management

• Lead defect triage meetings with business, QA, and development teams.
• Review, prioritize, and track defects through closure.
• Perform or guide root-cause analysis for complex claims-related defects.
• Ensure defects are properly documented and aligned with business impact and severity.
• Track testing and defect metrics and communicate quality status to stakeholders.

Stakeholder & Onsite Coordination

• Act as the primary onsite point of contact for claims domain and testing activities.
• Partner closely with Product Owners, business users, claims operations, development teams, QA leads, and offshore UAT/CoE teams.
• Facilitate requirement workshops, walkthroughs, test-result reviews, and business clarification sessions.
• Translate business requirements and payer rules into system impacts and actionable test scenarios.
• Communicate testing progress, risks, dependencies, and mitigation plans to project leadership.

Team Leadership & Mentoring

• Mentor junior and mid-level testers and analysts on US healthcare claims and NASCO concepts.
• Review test artifacts prepared by onsite and offshore teams.
• Guide offshore UAT teams to ensure domain accuracy and adequate test coverage.
• Promote best practices for domain-driven testing, UAT, defect management, and knowledge sharing.

Required Skills & Qualifications

• 15+ years of experience in US Healthcare Insurance, claims systems, testing, or related payer applications.
• Extensive hands-on experience with NASCO Claims Processing.
• Strong understanding of the end-to-end healthcare claims lifecycle and adjudication process.
• Strong experience with Healthcare Claims Testing and UAT.
• Experience leading testing activities as a Test Lead, UAT Lead, Claims SME, or Onsite Coordinator.
• Strong knowledge of professional, institutional, and pharmacy claims.
• Expertise in claims adjudication, pricing/repricing, benefits, deductibles, accumulators, MOOP, COB, subrogation, and authorizations.
• Strong understanding of EDI 837, 835, and 270/271 transactions.
• Knowledge of CMS, HIPAA, Medicare, Medicaid, and commercial payer requirements.
• Experience creating and reviewing test strategies, test plans, test scenarios, test cases, and test data.
• Strong defect management and root-cause analysis experience.
• Experience with test/defect management tools such as JIRA and ALM.
• Excellent stakeholder communication and client-facing skills.
• Ability to coordinate effectively between onsite business teams and offshore QA/UAT teams.
• Must be comfortable working onsite in Newark, NJ.

Key Skills

NASCO | Healthcare Claims | Claims Adjudication | US Healthcare Payer | UAT | Claims Testing | Professional Claims | Institutional Claims | Pharmacy Claims | EDI 837 | EDI 835 | EDI 270/271 | Medicare | Medicaid | CMS | HIPAA | COB | Subrogation | Accumulators | Deductibles | MOOP | Test Strategy | Defect Management | JIRA | ALM | Onsite Test Lead