Claims Processor Role Summary
Claims Processors support US healthcare payer claims operations by performing accurate and compliant end-to-end medical claims adjudication within the TriZetto Facets platform. The role ensures the correct application of advantages, pricing logic, provider validation, and payer rules while managing pended, exception, and reprocessed claims. Working in a highly workflow-driven environment, Claims Processors are responsible for aligning Facets system logic, claim data, and payment outcomes while maintaining productivity, quality, and compliance standards.
Key Responsibilities
End-to-End Claims Adjudication
• Process medical claims in the TriZetto Facets Claims module, including claim review, adjudication, pend/suspend handling, corrected claims, and reprocessing as required.
• Review member eligibility, benefits, claim type, provider information, and claim routing prior to final adjudication.
• Ensure accurate application of deductibles, copays, coinsurance, covered and non-covered services, and 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 interactions, and claim setup issues.
Workflow Alignment
• Support claim processing in alignment with claim submission and payment workflows, including claim status review, corrected claims, EOP interpretation, COB/TPL handling, and suspension/rejection analysis.
• Analyze and resolve eligibility-related pends, pricing and benefit validation pends, and provider or routing-related exceptions.
• Ensure timely resolution of suspended claims, rejected claims, and claims requiring rework or escalation.
• Process claims associated with BlueCard and shared administration workflows, including plan prefix identification, routing logic, home and host plan considerations, a
📌 Claims Specialist (Chennai)
🏢 UST
📍 Chennai