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 workplace 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 Perks-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

📌 Claims Processor (Thiruvananthapuram)
🏢 Closing Gap
📍 Thiruvananthapuram