NASCO claims Specialist

Job Title: NASCO claims Specialist

Location: Remote

Fulltime

Job Descriptions:

Key Responsibilities:

Serve as primary SME for end to end NASCO claims processing across professional, institutional, and pharmacy claims.

Provide strategic direction and domain leadership for claims testing initiatives.

Interpret and guide implementation of complex payer rules, benefit configurations, and provider contracts.

Review and validate regulatory compliance with CMS, HIPAA, Medicare, Medicaid, and commercial plan requirements.

Proactively identify domain risks, gaps, and improvement opportunities in claims workflows.

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Testing Strategy & Governance

Define overall NASCO claims testing strategy, scope, and coverage for releases.

Review and approve test plans, scenarios, and test data from a domain correctness perspective.

Ensure comprehensive validation of:

o Claims adjudication logic

o Pricing and repricing

o Accumulators (deductibles, MOOP)

o COB and subrogation

o Authorizations, edits, and exceptions

Lead UAT planning and execution, including business readiness and sign off.

Own defect triage decisions, prioritization, and root cause analysis.

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Stakeholder & Onsite Engagement

Act as single point of contact for claims domain queries at client location.

Partner closely with:

o Product Owners

o Business Users

o Operations teams

o Development and QA leads

Facilitate workshops, walkthroughs, and requirement clarification sessions.

Influence decision making by translating business needs into system impacts.

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Team Leadership & Mentorship

Mentor junior and mid level testers and analysts on healthcare claims concepts.

Review test artefacts and guide offshore UAT teams to ensure domain accuracy.

Promote best practices in domain driven testing and knowledge sharing.

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Required Skills & Qualifications

Mandatory Domain Expertise

Extensive experience in US Healthcare Insurance NASCO Claims Processing.

Strong understanding of:

o Claims lifecycle and adjudication engines

o EDI (837, 835, 270/271)

o Coding standards: ICD 10, CPT, HCPCS, DRG

o Commercial, Medicare, and Medicaid plans

Hands on experience supporting core payer platforms.

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Testing & Process Excellence

Strong manual testing background with senior level oversight experience.

Expertise in:

o Test strategy definition

o UAT leadership

o Defect governance

Familiarity with Agile, SAFe, or hybrid delivery models.

Experience with test management and defect tracking tools (Jira, ALM, qTest).