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.

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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: $100,000- $125,000 a year

TCS Employee Benefits Summary:

Discretionary Annual Incentive.

Comprehensive Medical Coverage: Medical & Health, Dental & Vision, Disability Planning & Insurance, Pet Insurance Plans.

Family Support: Maternal & Parental Leaves.

Insurance Options: Auto & Home Insurance, Identity Theft Protection.

Convenience & Professional Growth: Commuter Benefits & Certification & amp; Training Reimbursement.

Time Off: Vacation, Time Off, Sick Leave & Holidays.

Legal & Financial Assistance: Legal Assistance, 401K Plan, Performance Bonus, College Fund, Student Loan Refinancing.

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