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251 Milwaukee Ave, Buffalo grove, IL 60089
Web : http://www.xlysi.com
E-mail: hr@xlysi.com
Claims QA Lead | REMOTE | W2 Only.
Role Summary
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.
Key Responsibilities
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, overpayment 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.
Required Qualifications
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 DevOps, TestRail).
Excellent communication, analytical, and leadership skills.
Preferred Qualifications
Hands-on experience with claims platforms such as Facets, QNXT, HealthEdge, 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. are these roles same or different
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.
Key Responsibilities
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, overpayment 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.
Required Qualifications
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 DevOps, TestRail).
Excellent communication, analytical, and leadership skills.
Preferred Qualifications
Hands-on experience with claims platforms such as Facets, QNXT, HealthEdge, 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. are these roles same or different
HR
Xlysi LLC, Expert Portal Solutions251 Milwaukee Ave, Buffalo grove, IL 60089
Web : http://www.xlysi.com
E-mail: hr@xlysi.com
Our training portal registration:
http://xlysi.catsone.com/careers/index.php?m=portal&a=apply&jobOrderID=345179&portalID=2106