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 advantages, 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 accura

📌 Claims Specialist+Facet (Chennai)
🏢 UST
📍 Chennai