Claims Processor – US Healthcare Payer (FACETS) | BPM

Experience: 3 to 5 Years

Domain: US Healthcare Payer / Healthcare BPM

Employment Type: Full-Time

Location : Bangalore, Chennai, Trivandrum

Salary as per industry standards

Key Responsibilities

1. Claims Processing & Adjudication

- Process medical claims end-to-end using the TriZetto FACETS Claims module.
- Review claims for member eligibility, benefits, provider details, claim type, and routing.
- Handle pended, suspended, rejected, corrected, adjusted, and reprocessed claims.
- Apply deductibles, copayments, coinsurance, coverage limitations, authorization, and referral rules.
- Investigate claim discrepancies and resolve adjudication errors.

1. Claims Pricing & Advantages Validation

- Apply fee schedules, contractual payment rules, and institutional reimbursement methodologies.
- Validate provider contracts, benefit plans, and reimbursement rules.
- Identify and resolve pricing discrepancies and benefit configuration issues.
- Ensure accurate claim payments in accordance with payer guidelines.

1. Workflow & Healthcare BPM Operations

- Review claim status, Explanation of Payment (EOP), and payment-related exceptions.
- Handle Coordination of Benefits (COB), Third-Party Liability (TPL), and corrected claims.
- Analyze eligibility, pricing, provider-related, and routing exceptions.
- Support BlueCard and Blue Plan workflows, including Home and Host plan routing and out-of-area claims, where applicable.
- Meet defined productivity, accuracy, quality, and SLA targets in a BPM/BPO environment.

1.



Coding, Compliance & Quality

- Validate coding and billing information using ICD-10-CM, CPT, HCPCS, and DRG standards, as applicable.
- Follow HIPAA regulations, payer policies, documentation requirements, and internal quality controls.
- Maintain accurate processing records and support audits and continuous improvement initiatives.

Mandatory Skills
- Hands-on experience with TriZetto FACETS Claims processing .
- US Healthcare Payer Claims Processing.
- Medical Claims Adjudication and Claims Management.
- Understanding of benefits, eligibility, provider validation, and claims pricing.
- Knowledge of HIPAA and ICD-10-CM.
- Experience handling claim edits, pends, adjustments, rework, and exceptions.
- Strong analytical, problem-solving, and communication skills.

Preferred Skills
- Healthcare BPM/BPO operations.
- BlueCard and Blue Plan claims processing.
- COB/TPL, corrected claims, and payment integrity.
- Provider Data Management.
- CPT, HCPCS, and DRG coding and billing standards.
- Availity Essentials or equivalent healthcare payer tools.
- Experience working with SLA-driven claims workflows.

Educational Qualifications
- Graduation is mandatory.
- Preferred qualifications: B.Tech, B.E., BCA, B.Sc. IT, M.Sc. IT, or MCA.

Experience Requirements
- Minimum 3 + years of experience in US Healthcare Payer Claims Processing and Healthcare BPM operations .
- Hands-on experience with TriZetto FACETS is mandatory.
- Experience in a healthcare BPM/BPO environment is preferred.

📌 Associate III - BPM- Claim Processor (Bengaluru)
🏢 Talent Basket
📍 Bengaluru