Team Lead, Configuration Testing - Networx/GuidingCare

Job Summary:

Team Lead, Configuration Testing (Facets/ GuidingCare ) – Local/Relocation is preferred

We are looking for a Test Engineering Transformation Team Lead with 10+ years of experience in Facets/ GuidingCare configuration to lead quality transformation in a high-performing Operations department that upholds near-zero production defect leakage and strict SLA compliance. This role requires a strategic leader to drive testing excellence, enhance processes, and ensure seamless system performance in a fast-paced, high-stakes environment with highest possible auto-adjudication rates (> 99%).

Essential Functions:

• Mastery of Facets end-to-end claims processing, including member and provider match logics, pre-adjudication, post-adjudication, check write, mass claims adjustments, batch processing, remittance advice, and reimbursement methodologies.
• Expertise in Clinical Workflows using GuidingCare solution suite, including Care Management, Utilization Management, and Appeals & Grievances
• Facets Pricing:
  • Knowledge in evaluating fee schedule source documents from CMS or other applicable data sources, analyze reimbursement methods, and schedule loads to support proper payment based on provider contractual agreements
  • Proficient in interpretation and analysis of provider contracts, determine reimbursement structures and payment terms, and validate contract templates
  • Proven ability in validating the translation of complex provider contracts into pricing configuration
  • Knowledge in Facets pricing configuration models, including provider contracting and network setup, specific code pricing, fee schedule to ensure accurate claims pricing
  • Deep proficiency in TriZetto NetworX Modeler (including data structures) for impacted agreement testing
  • Analyze Production claim impact reports to determine if claims are priced correctly.
• Facets Benefits:
  • Ability to interpret Benefits configuration architecture to perform claims root cause analysis
  • Extensive hands-on experience in testing the configuration of Facets Benefits for member benefits setup (products, benefits, and plans) including appropriate claim edits
  • Experience in testing benefits cost shares, PCA, and use of Workflow to solve for UM, COB, Provider, and member match issues
  • Experience in OPTUM Claims Edit System (CES) configuration testing
• GuidingCare:
  • Extensive experience in testing the entire authorization lifecycle, from request submission and review to status determination and communication with members and providers.
  • Skilled in validating configurable appeal workflows and ensuring seamless integration with other modules.
  • Specialized in test data creation techniques for Health Risk Assessment (HRA) rules, ensuring comprehensive and accurate test coverage
• Facets/ GuidingCare upgrade: Strategic thinker with a sharp eye for test coverage optimization, adept at designing comprehensive test strategies for yearly system upgrades
• Proficient in API Testing, with hands-on experience in Facets Open Access APIs and GuidingCare APIs
• EDI: Deep expertise in healthcare X12 transaction sets (837, 835, 270/271, 276/277, 278, and 834

Education and Experience:

• Associates Degree or equivalent years of relevant work experience is required
• Minimum of ten (10) years of health plan business or systems solutions experience is required
• Exposure to Facets/ GuidingCare or equivalent system is preferred
• Prior supervisory experience is preferred

Competencies, Knowledge and Skills:

• Advanced expertise in Microsoft SQL Server Management Studio, with hands-on experience in Stored Procedures, Views, Triggers, and Cursors, focused on performance tuning, query optimization, and database management.
• Highly proficient in SQL for complex querying, data extraction, management, and optimization, with advanced capabilities in data analysis—seamlessly transferring data from SQL to Excel and utilizing pivot tables for insightful reporting.
• In-depth knowledge of TriZetto Facets database architecture, including core tables and components for querying and data validation.
• Proven ability to deliver hands-on support for Facets / GuidingCare configuration design and troubleshooting, with a strong focus on problem-solving and system optimization.
• Test Automation Support:
  • Collaborate closely with the automation development team to define and prioritize test requirements, conduct thorough unit testing, and drive the adoption of advanced test tools, ensuring a seamless transition to automated testing and enhanced operational efficiency.
  • Experience with custom scripting (Python), programming (C# .NET), and advanced automated testing frameworks such as OpenAI's GPT-4o, RPA tools like UiPath to streamline processes and increase test coverage.
  • Strong understanding of source code management tools (e.g., Git), ensuring consistent version control and smooth integration across development cycles.

Healthcare Industry Knowledge:

• Strong familiarity with the U.S. healthcare payer industry, with an in-depth understanding of Medicaid, Medicare, Marketplace programs
• Knowledge of reimbursement models, including fee-for-service, bundled payments, and value-based care
• Knowledge of medical terminology, claims processing guidelines, industry vernacular, code sets associated with system configuration and basic billing knowledge
• Comprehensive knowledge of DRG, SNF, RBRVS, Outliers and APC reimbursement methodologies
• Proficiency in medical coding standards, including CPT, HCPCS, and ICD-CM codes, ensuring compliance and accuracy in claims processing
• Knowledge in Clinical management

Licensure and Certification:

• TriZetto Facets Certification
• HealthEdge GuidingCare University courses
• UiPath RPA Certifications (Automation & AI-driven process optimization)
• .NET Development Certifications (C#/.NET framework expertise)
• Microsoft SQL Server Certification (Azure) (Database management & optimization)
• GenAI Certifications (AI-driven automation & data intelligence)
• Certified Professional Coder (CPC) designation
• Any relevant certifications in healthcare IT Payers domain

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.