Job Description :
Claims QA Analyst,
Hopkins, MN
6+ Months Contract
Phone + In-Person
Description:
* Minimum years'' experience required in claims processing and testing to qualify for the position: 3+ years (someone coming from a claims processing background that moved into testing would be ideal)
* Ability to show analytical qualities through information gathering and preparation in the form of business requirements, test plans, cases and scenarios, presentations, diagrams etc would be ideal. Would be open to someone with some UAT testing or open to being taught how to test)
* 2 years healthcare payor experience in one of the following (must be
recent)
* Written and verbal communication to communicate effectively with developers, business analysts, project managers, and functional managers
* Experience in Agile QA and SDLC lifecycles, best practices, and tools
* Understanding of Claims Platform
* Ability to think quickly and provide analysis, questions and facts to the team
The ideal candidate could be a business claims processing specialist who has done some UAT testing, or wants to get into IT - we would be willing to teach them how to test, if they had the above experience
MUST HAVES:
1. Ability to process a claim - understands how to process a claim against a benefit and understands the various components of claim payment, such as member responsibility, plan paid, contracted rate
2. Understands co-pay vs co-insurance, and understands how a claim flows thru the system against a benefit to ensure the claim was payed correctly
3. The candidate would start with a claim in the system (HealthEdge HealthRules Payor) and be able to look at the claim and determine how the system would correctly adjudicate that claim against the benefit that was configured.
* For example: A claim is submitted by a physician for a checkup, the
physician submits the claim line for the checkup for the appropriate Diagnosis code, appropriate ICD10 code and with a billed amount of $100
* This person would understand how to look at the diagnosis code and
the ICD10 code, trace back thru the configured benefit and the physician contracted rate to determine that the claim would be paid as follows:
Allowed Amount: $50 (due to a physician contracted rate), Member
Responsibility: $10 (due to a $10 copay
configured), Plan Paid: $40 50 - $10 Etc.