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: $110,000- $115,000 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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