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 () 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