QA - PBM

Key Responsibilities

• Perform end-to-end testing across SIT, UAT, Regression, Parallel Testing, and Production Validation phases.
• Validate healthcare and pharmacy business processes including claims adjudication, prior authorization, formulary management, rebates, and pharmacy financial reconciliation.
• Develop and execute test strategies, test plans, test cases, and test execution schedules.
• Analyze business requirements and ensure testing aligns with CMS guidelines and Medicaid regulations.
• Perform backend data validation and analysis using SQL.
• Manage defects using ALM/JIRA and drive resolution with cross-functional teams.
• Collaborate with business stakeholders, developers, vendors, and SMEs to ensure successful project delivery.
• Prepare and maintain testing artifacts, including BRDs, FRDs, RTMs, process flows, and test reports.
• Monitor quality metrics, risks, issues, and provide regular status updates to leadership teams.

Required Skills & Experience

• 5+ years of experience in Healthcare IT, Health Insurance, Medicaid, Medicare, or PBM environments.
• Strong understanding of:
• Claims Adjudication
• Prior Authorization
• Pharmacy Benefit Management
• Formulary Management
• Drug Rebate Processing
• NCPDP Transactions
• Hands-on experience with SQL for data validation and analysis.
• Experience using ALM, JIRA, or similar test management tools.
• Familiarity with MMIS platforms, PBM systems, or healthcare portals.
• Strong documentation skills, including BRDs, FRDs, test cases, and process flows.
• Experience working in Agile/Scrum environments.
• Excellent communication and stakeholder management skills.