Claims Specialist+Facet

UST · India

Claims Processor Role Summary Claims Processors to support US healthcare payer claims operations Responsible for accurate and compliant end-to-end medical claims adjudication within the TriZetto Facets platform, ensuring proper application of benefits, pricing logic, provider validation, and payer rules. The role operates within a highly workflow-driven environment, handling pended, exception, and reprocessed claims, while ensuring alignment between Facets system logic, claim data, and final payment outcomes with strong adherence to productivity, quality, and compliance expectations. Key Responsibilities End-to-End Claims Adjudication • Process medical claims in TriZetto Facets Claims module, including review, adjudication, pend/suspend handling, corrected claims, and reprocessing as required. • Review member eligibility, benefits, claim type, provider details, and claim routing before final adjudication. • Ensure correct application of Deductibles, copay, and coinsurance, Covered vs non-covered services Authorization and referral requirements. • Apply appropriate pricing methodologies within Facets, including Fee schedule-based pricing, Institutional reimbursement logic, and Contractual payment rules. • Identify and resolve discrepancies related to Pricing configuration, Benefit-plan interaction, Claim setup issues. Workflow Alignment • Support claim handling aligned to Claim submission and payment workflows, including claim status review, corrected claims, EOP understanding, COB/TPL handling, and suspension/rejection analysis. • Analyze and resolve Eligibility-related pends, Pricing and benefit validation pends, Provider or routing-related exceptions. • Ensure timely handling of Suspended claims, Rejected claims, and Claims requiring rework or escalation. • Process claims aligned to BlueCard and shared administration workflows, including Plan prefix identification and routing logic, Home and host plan considerations, and Out-of-area claim handling to ensure accurate coordination between plans and proper claim direction. Coding / Compliance • Validate coding and billing elements using ICD-10, CPT, HCPCS, and DRG-related billing standards as applicable to payer claims processing. • Ensure compliance with payer guidelines, HIPAA, documentation expectations, and internal audit/control requirements. Tools & Systems Exposure • TriZetto Facets – Claims, Workflow, pricing and benefits-linked adjudication. • Availity Essentials or equivalent tools for eligibility, benefits, claim status, and related servicing activity. • Coding and billing references, payment policy references, and EOP review tools. Mandatory Skills & Competencies • Strong hands-on experience in Facets Claims processing with knowledge of adjudication flow, edits, pends, adjustments, and rework. • Good understanding of benefits, provider validation, claim pricing, and reimbursement logic in a payer environment. • Preferred exposure to Blue plan workflows including BlueCard, payment integrity, corrected claims, and claim edit handling. Qualifications • Graduate (Mandatory). • 5+ years of experience in US Healthcare Payer Claims Processing. • Experience in TriZetto Facets is mandatory

Skills