Claims QA Lead | REMOTE | W2

We are seeking a QA Lead with strong domain expertise in healthcare claims processing to lead quality assurance for our claims adjudication and payment platforms. You will ensure claims are received, adjudicated, priced, and paid correctly according to benefit plans, contracts, and regulatory rules, while leading a QA team and driving automation and release quality.

• Define and drive the QA strategy for the full claims lifecycle: intake, edits, eligibility checks, pricing, adjudication, payment, and remittance.
• Lead functional, regression, integration, and end-to-end testing of professional, institutional, and dental claims (837P/837I/837D) and remittance outputs (835).
• Validate adjudication logic, including benefit configuration, accumulators (deductibles, out-of-pocket maximums), copay and coinsurance, prior authorization and referral rules, and coordination of benefits (COB).
• Test provider contract pricing and fee schedules (DRG, per diem, case rate, percent-of-charge, RBRVS) and claim edits (NCCI, MUE, medical necessity).
• Verify claims adjustments, reversals, reprocessing, over payment recovery, and timely filing logic.
• Test claims-related integrations with eligibility (834), enrollment, provider, authorization (278), and finance systems.
• Support validation of regulatory requirements, including prompt pay, appeals and grievances, and mandated reporting.
• Build and maintain automated test suites for claims scenarios and configuration changes, and create reusable test data.
• Lead defect triage and root cause analysis, working with developers, business analysts, and operations.
• Define and report QA metrics (auto-adjudication rate, payment accuracy, defect density, test coverage).
• Mentor and manage QA team members; enforce testing standards and best practices.
• Coordinate UAT with claims operations and support production release validation and post-deployment monitoring.

• 8+ years in QA/testing, with 3+ years leading teams.
• 4+ years of hands‑on experience testing healthcare claims systems (payer or TPA environments).
• Strong understanding of claims adjudication workflows, benefit plans, COB, and provider reimbursement methodologies.
• Working knowledge of X12 5010 transactions (837, 835, 834, 278, 277) and HIPAA requirements.
• Solid grasp of medical coding: ICD-10, CPT, HCPCS, revenue codes, modifiers, and place of service.
• Proficiency in SQL for validating claims data and financial outcomes.
• Experience with test automation (e.g., Selenium, Cucumber, Postman, Python/Java) and API testing.
• Experience with test management and defect tools (JIRA, Azure Dev Ops, Test Rail).
• Excellent communication, analytical, and leadership skills.

• Hands‑on experience with claims platforms such as Facets, QNXT, Health Edge, Amisys, or similar.
• Experience with Medicare Advantage, Medicaid managed care, ACA/Marketplace, or commercial lines of business.
• Familiarity with claims editing and payment integrity tools and clearinghouse workflows.
• Experience with CI/CD, test data management, and performance testing.
• Certifications such as ISTQB, CSTE, AHIP, or CPC.
• Experience in Agile/SAFe delivery models.

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