Claims Processor – US Healthcare Payer |

Experience: 5+ Years

Location: Chennai, Bangalore, Trivandrum

Job Overview

We are looking for experienced US Healthcare Payer Claims Processors with strong hands-on experience in TriZetto FACETS.

Key Responsibilities

- Process and adjudicate medical claims using TriZetto FACETS.
- Review member eligibility, advantages, provider information, claim type and routing.
- Handle pended, suspended, rejected, corrected and reprocessed claims.
- Apply deductibles, copays, coinsurance and covered/non-covered service rules.
- Review and apply appropriate pricing and reimbursement logic, including fee schedules and contractual payment rules.
- Identify and resolve eligibility, benefits, pricing, provider and claim setup discrepancies.
- Handle COB/TPL, claim status, EOP and corrected claim workflows.
- Analyze claim edits, exceptions and suspension/rejection reasons and perform necessary rework or escalation.
- Support BlueCard and Home/Host plan workflows, including plan prefix identification and out-of-area claims.
- Validate coding and billing information using ICD-10-CM,



CPT and HCPCS as applicable.
- Maintain required productivity, quality, SLA and compliance standards.
- Follow HIPAA, payer guidelines and internal quality/control requirements.
- Contribute to process improvement and operational excellence initiatives.

Mandatory Requirements

- 5+ years of experience in US Healthcare Payer Claims Processing / Healthcare BPM operations.
- Hands-on experience with TriZetto FACETS is mandatory.
- Strong understanding of claims adjudication, edits, pends, adjustments and reprocessing.
- Good knowledge of member benefits, eligibility, provider validation, pricing and reimbursement.
- Experience working in a Healthcare BPM/BPO environment.
- Graduate degree is mandatory.
- Strong analytical, problem-solving and communication skills.

Key Skills: TriZetto FACETS | US Healthcare Claims | Claims Adjudication | HIPAA | ICD-10-CM | Claims Management | Provider Data Management

Interested candidates can share their updated CV or connect with [email protected]

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