NASCO claims Specialist

Key Responsibilities

• 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.

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.

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.

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.

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.

Testing & Process Excellence

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

oTest strategy definition

oUAT leadership

oDefect governance

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