Claims Processor – US Healthcare Payer (FACETS)

Job Summary

We are looking for experienced Claims Processors to support US Healthcare Payer and BPM operations. The role involves accurate and compliant end-to-end medical claims adjudication using the TriZetto FACETS platform.

The ideal candidate should have strong knowledge of healthcare benefits, claims pricing, provider validation, payer rules, and claims workflows. The role will involve handling pended, exception, corrected, and reprocessed claims while meeting defined productivity, quality, SLA, and compliance requirements.

Multiple location : Bangalore , Trivandrum, Hyderabad, Chennai

Key Responsibilities

1. End-to-End Claims Adjudication

• Process medical claims using the TriZetto FACETS Claims module.

• Review, adjudicate, pend/suspend, correct, and reprocess claims as required.

• Validate member eligibility, benefits, claim type, provider information, and claim routing.

• Apply appropriate benefit rules, including:

• Deductibles

• Copay and coinsurance

• Covered and non-covered services

• Authorization and referral requirements

• Identify and resolve claim pricing, benefit-plan, and claim setup discrepancies.

2. Claims Workflow & BPM Operations

• Handle claims in accordance with defined submission, adjudication, and payment workflows.

• Review claim status, corrected claims, EOP, COB/TPL, and suspension/rejection scenarios.

• Analyze and resolve:

• Eligibility-related pends

• Pricing and benefit validation pends

• Provider-related exceptions

• Routing issues

• Ensure timely processing of suspended, rejected, and rework claims.

• Support BlueCard and shared administration workflows, including:

• Plan prefix identification

• Routing logic

• Home and Host Plan considerations

• Out-of-area claim handling

• Adhere to BPM/BPO SLA, productivity, quality, and operational governance requirements.

3. Claims Pricing & Reimbursement

• Apply appropriate pricing methodologies within FACETS.

• Work with:

• Fee schedule-based pricing

• Institutional reimbursement logic

• Contractual payment rules

• Identify and resolve pricing and reimbursement discrepancies.

• Understand the interaction between benefits, provider contracts, pricing, and claim adjudication.

4. Coding & Compliance

• Validate coding and billing elements using applicable:

• ICD-10-CM

• CPT

• HCPCS

• DRG-related billing standards

• Ensure adherence to payer guidelines, HIPAA, documentation requirements, and internal controls.

• Follow defined quality, compliance, audit, and operational standards.

5. Quality & Process Improvement

• Maintain high levels of claims accuracy and quality.
• Identify recurring claim errors, workflow gaps, and operational issues.
• Support continuous improvement and operational excellence initiatives.
• Meet defined productivity, quality, SLA, and turnaround-time targets.

6. Tools & Systems

• TriZetto FACETS – Claims, Workflow, Pricing, and Benefits.
• Availity Essentials or equivalent payer tools.
• Coding and billing reference tools.
• Payment policy and EOP review tools.

Mandatory Skills & Competencies

• Strong hands-on experience in FACETS Claims Processing.

• Knowledge of:

• Claims adjudication

• Claims edits and pends

• Claims adjustments and rework

• Benefits administration

• Provider validation

• Claims pricing

• Reimbursement logic

• Experience in US Healthcare Payer Claims Processing.

• Experience in a Healthcare BPM/BPO environment.

• Strong understanding of SLA-driven operations and workflow management.

• Good analytical and problem-solving skills.

• Strong communication and attention to detail.

Preferred Skills

• Experience with Blue Plan / BlueCard workflows.
• Shared administration.
• Payment integrity.
• Corrected claims and claim edit handling.
• Experience with Availity or similar payer platforms.
• Exposure to healthcare claims quality and audit processes.

Qualifications & Experience

• Graduate – Mandatory
• B.Tech / B.E. / MCA / BCA / M.Sc IT / B.Sc IT or equivalent.
• 3 to 5 years of experience in US Healthcare Payer Claims Processing and Healthcare BPM Operations.
• TriZetto FACETS experience is mandatory.
• Healthcare BPM/BPO experience preferred.