Job Description

Claims Domain Test Manager:

Summary:

Play the role of Claims Domain test manager for MMIS health care projects. Drive the test strategy and process, domain knowledge, perform analysis of business requirements, design and develop test plans, ensure 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.

Role & Responsibilities:

Should have strong health care domain experience and should have good knowledge of Medicaid and Medicare.
Should have hands-on experience on claims processing and Adjudication processes.
Must have good experience in Reference code/data sets required in Claims adjudication.
Must have prior experience or understanding in configuring benefits or programs in claims system across various sub-systems.
Should be able to run queries and perform basic system analysis, RCA etc.,
Should work closely with the client and development team during the stages of development, and conduct demos at completion of milestones, track and close feedback from such demos
Must have excellent written and spoken communication skills. Should be able to multitask between internal team and clients based on priority tasks
Work Closely with Dev, architecture and Design teams to define the GUI view and platform requirements, which is the foundation of the product.
In depth understanding of Claims and Claims lifecycle:

Member
Provider
Claim submission - Paper and EDI X12
Adjudication
Payment Cycle (Finance)
Reporting

Claim Types:

Professional
Dental
Institutional
Pharmacy
Encounters and Capitation

Claim Formats:

EDI X12 formats like 837P/I/D
X12 formats 835, 834, 270/271, 276/277

Claim System:

Familiarity with systems like CMdS, GHS, Facets and etc

Testing knowledge and E2E Testing:

Validate the entire flow from claim intake to payment and reporting.
Interface testing - Test integration points between systems
Design test case 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

Minimum of 10+ years of experience in health care experience especially in MMIS domain.
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 use tools like postman
Capability to think out-of-the-box to create new solutions as needed.
Ability to validate Test scenarios and test plans, test data.
Should be able to Review requirements, documentation and create Requirements Traceability matrix (RTM)
Should have excellent communication (written and spoken) skills to engage with different stake holders like QA/dev team, clients, end users of Clients and Business Units.
Ability to assess current functionality available in a product vis a vis market trends, regulatory requirements to be implemented in future version of the product.
Ability to drive and share the requirements with Technical and Architects regarding product features to be implemented.
Test Planning & Reporting: Create test plans, test summary reports, and traceability matrices.
Communication: Collaborate with cross-functional teams including developers, SME's and BA's

Pay Transparency Laws in some locations require disclosure of compensation and/or benefits-related information. For this position, actual salaries will vary and may be above or below the range based on various factors including but not limited to location, experience, and performance. In addition to base pay, this position, based on business need, may be eligible for a bonus or incentive. In addition, Conduent provides a variety of benefits to employees including health insurance coverage, voluntary dental and vision programs, life and disability insurance, a retirement savings plan, paid holidays, and paid time off (PTO) or vacation and/or sick time. The estimated salary range for this role is $97,790 - $127,000.

Conduent

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