We are seeking an experienced Senior Test / QA Analyst to support a prominent West Coast healthcare client focused on health plan claims processing systems. This require a high-level QA professional who can hit the ground running in a fast-paced payer environment.
In this role, you will leverage your deep expertise in healthcare claims adjudication, EDI transaction testing, regulatory compliance, and enterprise quality assurance methodologies. The ideal candidate is highly analytical, detail-oriented, and has a proven track record of leading testing efforts across complex payer environments involving medical, pharmacy, and dental/vision claims.
What You Will Do
As a Senior QA Analyst, you will design, develop, and execute comprehensive test strategies while collaborating cross-functionally within Agile teams. Your core responsibilities will include:
- Test Strategy & Execution: Design and execute comprehensive test plans, test cases, and test scripts for health plan claims processing systems.
- Workflow Validation: Validate end-to-end claims adjudication workflows including intake, pricing, benefit application, coordination of benefits (COB), payment processing, and EOB generation.
- EDI & Transaction Testing: Perform robust testing and validation of HIPAA-compliant EDI transaction sets including 837P/837I, 835, 270/271, 276/277, and 834 transactions.
- Financial & Pricing Accuracy: Verify claims payment accuracy against fee schedules, contracted provider rates, DRG/APR-DRG methodologies, per diem structures, and MAC pricing logic.
- System & Core Admin Testing: Test auto-adjudication workflows, prior authorization integrations, manual review queues, and claims editing logic across core platforms.
- Defect Management: Lead defect triage, root cause analysis, regression testing, and release validation.
- Data Validation: Utilize SQL for deep-dive test data validation and backend verification activities.
- Compliance Verification: Ensure strict compliance with ACA, CMS, NCQA, HIPAA, state DOI mandates, and validate code set updates (ICD-10-CM/PCS, CPT, HCPCS, NDC, and revenue code tables).
- Cross-Functional Collaboration: Partner with business analysts, claims operations, developers, and external trading partners to translate requirements into testable scenarios, while mentoring junior QA staff.
What You Will Bring
To be successful in this role, you must bring a blend of strong technical QA skills and deep functional knowledge of payer operations.
Required Experience & Skills:
- Experience: 5+ years of software QA/testing experience, with at least 3 years specifically supporting health plan claims processing systems .
- Claims Adjudication: Strong experience with medical claims adjudication including COB, subrogation, remittance processing, and claims editing platforms (e.g., ClaimL