Claims Processor

We are looking for an experienced Claims Processor with strong experience in US Healthcare Payer Claims Processing and hands-on expertise in TriZetto FACETS Claims.

The role involves end-to-end medical claims adjudication, including eligibility and benefits review, provider validation, claim pricing, pended and exception claims, corrected claims, reprocessing, and workflow-driven healthcare BPM operations.

Key Responsibilities

• Process medical claims end-to-end using the TriZetto FACETS Claims module.
• Review and adjudicate claims, including pend/suspend handling, corrected claims, adjustments, and reprocessing.
• Verify member eligibility, benefits, claim type, provider details, claim routing, and claim setup information.
• Apply deductibles, copays, coinsurance, covered/non-covered service rules, authorization, and referral requirements.
• Work with FACETS pricing and reimbursement logic, including fee-schedule-based pricing, institutional reimbursement, and contractual payment rules.
• Identify and resolve issues related to pricing configuration, benefit plans, provider information, claim setup, and routing.
• Analyze and resolve eligibility, pricing, benefit validation, provider, routing, suspension, rejection, and rework-related exceptions.
• Handle corrected claims, claim status reviews, EOP-related activities, COB/TPL, and payment workflow requirements.
• Support BlueCard/shared administration workflows, including plan prefix identification, routing logic, Home/Host plan considerations, and out-of-area claims.
• Work within a healthcare BPM/BPO environment while meeting defined SLA, productivity, quality, compliance, and operational requirements.
• Support process improvement and operational excellence initiatives.

Coding & Compliance

• Validate coding and billing elements using ICD-10-CM, CPT, HCPCS, and DRG standards as applicable.
• Ensure claims are processed according to payer guidelines, HIPAA requirements, documentation standards, and internal audit/control requirements.

Tools & Systems

• TriZetto FACETS: Claims, Workflow, Pricing, and Benefits-linked adjudication.
• Availity Essentials or equivalent healthcare payer/claims servicing platforms.
• Coding, billing, payment policy, and EOP reference tools.

Mandatory Skills

• Hands-on experience in TriZetto FACETS Claims processing.
• Strong understanding of US Healthcare Payer Claims Adjudication.
• Knowledge of:
• Claims Processing
• Eligibility & Benefits
• Provider Validation
• Claim Pricing & Reimbursement
• Claim Edits & Exceptions
• Corrected Claims & Reprocessing
• COB / TPL
• EOP
• Claims Workflow
• Knowledge of HIPAA and ICD-10-CM.
• Experience in healthcare BPM/BPO operations.
• Strong analytical and problem-solving skills.
• Good communication and attention to detail.

Preferred Experience

• Blue Plan / BlueCard workflows.
• Payment integrity and claim edit handling.
• Corrected claims and reprocessing.
• Availity Essentials or similar payer platforms.
• Exposure to Claims Management and Provider Data Management.

Experience & Qualifications

• 3–5 years of relevant experience in US Healthcare Payer Claims Processing / Healthcare BPM Operations.
• Hands-on TriZetto FACETS Claims experience is mandatory.
• Healthcare BPM/BPO experience preferred.
• Graduate with BTech / MCA / BCA / MSc IT / BSc IT or equivalent qualification.

Key Performance Areas

• Claims processing and adjudication accuracy.
• Quality and first-pass accuracy.
• Productivity and SLA adherence.
• Claims turnaround time.
• Exception and pend resolution.
• Documentation and compliance.
• Rework and error reduction.

Work Locations: Chennai | Thiruvananthapuram | Bengaluru

Important: Candidates without hands-on TriZetto FACETS Claims experience may not be considered.

Apply now if you have relevant US Healthcare Payer Claims Processing experience with hands-on FACETS exposure.

Work Location: In person