NASCO claims Specialist

NASCO claims Specialist || Remote || Fulltime | 8 - 16 years of experience

• Serve as primary SME for end to end NASCO claims processing across professional, institutional, and pharmacy claims.
• Provide strategic direction and domain leadership for claims testing initiatives.
• Interpret and guide implementation of complex payer rules, benefit configurations, and provider contracts.
• Review and validate regulatory compliance with CMS, HIPAA, Medicare, Medicaid, and commercial plan requirements.
• Proactively identify domain risks, gaps, and improvement opportunities in claims workflows.

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Testing Strategy & Governance

• Define overall NASCO claims testing strategy, scope, and coverage for releases.
• Review and approve test plans, scenarios, and test data from a domain correctness perspective.
• Ensure comprehensive validation of:

o Claims adjudication logic

o Pricing and repricing

o Accumulators (deductibles, MOOP)

o COB and subrogation

o Authorizations, edits, and exceptions

• Lead UAT planning and execution, including business readiness and sign off.
• Own defect triage decisions, prioritization, and root cause analysis.

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Stakeholder & Onsite Engagement

• Act as single point of contact for claims domain queries at client location.
• Partner closely with:

o Product Owners

o Business Users

o Operations teams

o Development and QA leads

• Facilitate workshops, walkthroughs, and requirement clarification sessions.
• Influence decision making by translating business needs into system impacts.

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Team Leadership & Mentorship

• Mentor junior and mid level testers and analysts on healthcare claims concepts.
• Review test artefacts and guide offshore UAT teams to ensure domain accuracy.
• Promote best practices in domain driven testing and knowledge sharing.

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Required Skills & Qualifications

Mandatory Domain Expertise

• Extensive experience in US Healthcare Insurance - NASCO Claims Processing.
• Strong understanding of:

o Claims lifecycle and adjudication engines

o EDI (837, 835, 270/271)

o Coding standards: ICD 10, CPT, HCPCS, DRG

o Commercial, Medicare, and Medicaid plans

• Hands on experience supporting core payer platforms.

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Testing & Process Excellence

• Strong manual testing background with senior level oversight experience.
• Expertise in:

o Test strategy definition

o UAT leadership

o Defect governance

• Familiarity with Agile, SAFe, or hybrid delivery models.
• Experience with test management and defect tracking tools (Jira, ALM, qTest).

Salary Range: $110,000- $115,000 a year

Diverse Lynx LLC is an Equal Employment Opportunity employer. All qualified applicants will receive due consideration for employment without any discrimination. All applicants will be evaluated solely on the basis of their ability, competence and their proven capability to perform the functions outlined in the corresponding role. We promote and support a diverse workforce across all levels in the company.