Analyze requirements and design comprehensive manual test cases and test scenarios for claims workflows within the Pega platform
– Develop test cases covering end-to-end claims workflows (enrollment, verification, adjudication, denial management, appeals, payment posting); ensure test cases align with business requirements and claims processing rules; document expected results with attention to benefit facet application
* Execute manual test cases within Pega environments (development, test, staging) to validate claims processing functionality and business rules
– Perform functional testing of Pega case activities, assignments, and workflows; validate claim adjudication accuracy; test benefit facet configurations (deductibles, copays, coinsurance); verify claim calculations and payment logic
* Validate Pega business rules engine and claims-specific configurations to ensure accurate claim processing
– Test Pega rule configurations (Decision Trees, Decision Tables, Constraints); validate claim decision logic and benefit facet rules; verify coverage determination and claim adjustment rules
* Test integration between Pega claims processing and external systems (eligibility/enrollment systems, medical management platforms, provider networks, payment systems)
– Validate data flow between Pega and integrated systems; test claim data imports and exports; verify payment posting to external systems; test error handling and data reconciliation
* Perform regression testing on Pega system updates, patches, and new releases to ensure existing claims functionality remains intact
– Execute regression test suites following Pega version upgrades; identify and report regressions in claims workflows and business rules; support hotfix validation and patch verification
* Conduct User Acceptance Testing (UAT) coordination and support, ensuring claims stakeholders can validate business requirements
– Prepare UAT test scripts and test data; coordinate with business users and claims teams; guide UAT execution; document defects and change requests; support UAT sign-off
* Document and report test results, defects, and issues using test management and defect tracking tools
– Create detailed test execution reports; log defects with clear reproduction steps and expected vs. actual results; track defect severity and priority; verify defect fixes through regression testing
* Collaborate with business analysts to understand claims workflows, benefit structures, and coverage rules impacting test design
– Communicate with claims domain experts to clarify requirements; validate test scenarios against business logic; identify edge cases and boundary conditions specific to claims processing
* Validate compliance with healthcare regulations and internal policies in Pega claims workflows
– Test claim processing logic for compliance with CMS regulations, state insurance laws, and HIPAA requirements; validate deny reasons and appeals workflows; verify audit trail and claim history logging
* Maintain test artifacts and support continuous improvement of testing processes
– Organize and maintain test case libraries and test data repositories; update test cases based on requirement changes; contribute to QA process improvements and test automation opportunities