QA Lead, Healthcare Encounters | Remote | W2

We are looking for a QA Lead with deep expertise in healthcare encounter data to own the test strategy, execution, and quality governance for our encounter processing platform. You will make sure encounter data is accurately generated, validated, submitted, and reconciled with state, federal, and plan partners, and you will lead a team of QA engineers while working closely with product, business analysts, and compliance.

• Define and own the end-to-end QA strategy for encounter data lifecycle: intake, validation, transformation, submission, rejection handling, and resubmission.
• Lead test planning, design, and execution for 837P/837I/837D encounter files and related acknowledgments (999, 277CA) and response files.
• Validate encounter submissions to regulators and partners (e.g., state Medicaid agencies, CMS MAO-004/EDPS, T-MSIS), including completeness, timeliness, and accuracy thresholds.
• Verify encounter-to-claim reconciliation, including paid, denied, adjusted, and voided claim scenarios, and the logic for replacement and void encounters.
• Design test scenarios for risk adjustment data flows, including diagnosis and provider data integrity.
• Build and maintain automated regression suites for encounter validation rules, edits, and mapping logic.
• Create and manage synthetic, de-identified test data sets that meet HIPAA requirements.
• Analyze rejection and error reports, perform root cause analysis, and drive defect resolution with development teams.
• Establish QA metrics and dashboards (defect leakage, rejection rates, test coverage, submission accuracy).
• Mentor and manage QA engineers; set standards for test documentation and review.
• Support UAT, regulatory audits, and production release validation.
• Partner with compliance to keep testing aligned with HIPAA, CMS, and state-specific encounter requirements.

• 8+ years in QA/testing, with 3+ years in a lead role.
• 4+ years of hands-on experience with healthcare encounter data (Medicaid managed care, Medicare Advantage, or commercial).
• Strong working knowledge of X12 5010 transactions (837, 835, 999, 277CA) and encounter data specifications.
• Solid understanding of medical coding: ICD-10-CM/PCS, CPT, HCPCS, revenue codes, place of service, and modifiers.
• Proficiency in SQL for data validation and reconciliation across large datasets.
• Experience with test automation frameworks (e.g., Selenium, Cucumber, Postman, REST Assured, Python/Java).
• Experience with test management and defect tools (JIRA, Azure Dev Ops, Test Rail, Zephyr).
• Strong analytical, communication, and stakeholder management skills.

• Experience with core administrative platforms (e.g., Facets, QNXT, Health Edge, Amisys) and encounter submission tools or clearinghouses.
• Familiarity with CMS EDGE server, MA encounter data processing, or state-specific Medicaid encounter companion guides.
• Experience with CI/CD pipelines, API testing, and data pipeline testing (ETL).
• Knowledge of FHIR/HL7 and interoperability standards.
• Certifications such as ISTQB, CSTE, CPC, or CHDA.
• Experience working in Agile/SAFe environments.

HR

HR Xlysi LLC, Expert Portal Solutions
251 Milwaukee Ave, Buffalo grove, IL 60089
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