Medicaid Claims QA Analyst(Healthcare)

Location: Remote. Type: Full Time/W2 with Infinite Computer Solutions.

About the role

Responsible for claims testing for MMIS health care projects. Drive the test strategy and process, domain knowledge, perform analysis of business requirements, designs and develops test plans, ensures quality process, coordinates with customers on delivery and deployments. Works in team environment and provides testing guidance throughout the entire life cycle. Responsible to meet customer expectations, troubleshoot problems in the application and assisting customers in implementation decisions.

Responsibilities

• Work closely with the client and development team during the stages of development, and conduct demos at completion of milestone, track and close feedback from such demos.
• Work closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
• Validate the entire flow from claim intake to payment and reporting.
• Perform interface testing — test integration points between systems.
• Design test cases based on business rules, coverage policies, and system configurations.

Requirements

• Strong health care domain experience with good knowledge of Medicaid and Medicare.
• Hands-on experience with claims processing and adjudication processes.
• Good experience with reference code/data sets required in claims adjudication.
• Prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
• Ability to run queries and perform basic system analysis, root cause analysis (RCA), etc.
• Excellent written and spoken communication skills.
• Ability to multitask between internal team and clients based on priority tasks.
• In-depth understanding of claims and claims lifecycle including: Member, Provider, Claim submission (Paper and EDI X12), Adjudication, Payment Cycle (Finance), Reporting.
• Knowledge of claim types: Professional, Dental, Institutional, Pharmacy, Encounters and Capitation.
• Familiarity with claim formats: EDI X12 formats like 837P/I/D, X12 formats 835, 834, 270/271, 276/277.
• Familiarity with claim systems such as CMdS, GHS, Facets, etc.

Testing knowledge & E2E testing

• Validate the entire flow from claim intake to payment and reporting.
• Interface testing — test integration points between systems.
• Design test cases based on business rules, coverage policies, and system configurations.
• Familiarity with test management tools like ADO, JIRA.
• Interface/API testing tools like Postman.

Technical skills

• SQL: to validate data in backend tables (e.g., claim status, payment details, find members/providers, Benefit Plan).
• EDI tools: validating X12 files.
• Interface testing: understanding how data flows between systems and formats and using tools like Postman.