PBM and Pharmacy Claims QA Tester

• Analyze NCPDP D.0 and F6 implementation requirements, payer sheets, field mapping documents, business rules, and transaction specifications to identify test scenarios and validation needs.
• Create and maintain test plans, test scenarios, test cases, test scripts, test data, and traceability for pharmacy claim transaction testing.
• Analyzes requirements, coordinate with BA s / Subject Matter Experts.
• Validate NCPDP pharmacy claim request and response transactions, including claim submission, reversal, eligibility, coordination of benefits, reject codes, messaging, pricing, accumulators, and coverage determination scenarios.
• Perform functional, regression, integration, end-to-end, batch, database, API/interface, UAT support, Parallel and production validation testing for D.0 to F6 changes.
• Develop and execute SQL queries to validate claims data, member eligibility, benefit setup, pricing, accumulators, drug data, payer configuration, and downstream reporting impacts.
• Compare D.0 and F6 transaction behavior to confirm that new, modified, and retired fields are processed correctly across impacted systems.
• Identify, document, track, retest, and close defects using approved defect management processes and tools.
• Support test data creation for positive, negative scenarios.
• Coordinate testing dependencies with PBM SME s, business users, developers, PBM teams, and downstream application teams.
• Coordinates Onshore / Offshore as needed.
• Working knowledge on AI tools for automation.
• Prepare daily or weekly status updates, defect reports, test execution metrics, test coverage summaries, and implementation risk updates.
• Participate in requirement reviews, design walkthroughs, payer sheet reviews, field mapping reviews, release readiness meetings, and implementation checkpoints.

We re looking for a Test Engineer with strong pharmacy claims and PBM testing experience to support an NCPDP D.0 to F6 implementation.

This role is responsible for validating transaction changes, claim adjudication outcomes, eligibility and coordination of benefits scenarios, reject messaging, payer sheet impacts, data mapping, regression coverage, and production readiness. The ideal candidate has strong pharmacy claims testing experience, working knowledge of NCPDP D.0, the ability to learn and validate F6 changes, strong SQL and data validation skills, and experience collaborating with PBM SME s, BA, development, and business teams.

Key experience: NCPDP D.0, NCPDP F6, PBM/pharmacy claims, SQL, SIT, UAT, Parallel, regression testing, trading partner testing, release testing, production validation, and post-implementation defect triage., * Minimum of 7 years of Quality Assurance or software testing experience, preferably in healthcare, PBM or pharmacy claims environments.

• Hands-on experience testing pharmacy claims, claim adjudication, eligibility, benefits, pricing, accumulators, reject codes, and claim response messaging.
• Working knowledge of NCPDP Telecommunication Standard Version D.0; exposure to Version F6 implementation or standards migration is strongly preferred.
• Experience creating test plans, test cases, test scripts, test estimates, test data, and traceability matrices.
• Strong understanding of SDLC methodologies, including Agile, Scrum, Waterfall, Iterative, or hybrid delivery models.
• Solid SQL experience for backend validation, data reconciliation, and claims data analysis.
• Experience with defect management, test execution tracking, QA reporting, and release validation.
• Ability to interpret transaction layouts, payer sheets, field-level requirements, business rules, and technical mapping documents.
• Strong analytical, troubleshooting, organizational, documentation, and problem-solving skills.
• Effective written and verbal communication skills with the ability to explain testing results, defects, and implementation risks to technical and business audiences.
• Ability to work independently and collaboratively in a fast-paced implementation environment.
• Bachelor s degree is preferred. Equivalent industry experience may be considered.