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 benefits, 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, and out-of-area claim handling to ensure accurate coordination and claim direction.

Coding and Compliance

- Validate coding and billing elements using ICD-10, CPT, HCPCS, and DRG billing standards applicable to payer claims processing.
- Ensure compliance with payer guidelines, HIPAA requirements, documentation standards, and internal audit and control processes.

Tools and Systems Exposure

- TriZetto Facets – Claims, workflow, pricing, and benefits-linked adjudication.
- Availity Essentials or equivalent tools for eligibility verification, benefits review, claim status, and related servicing activities.
- Coding and billing references, payment policy resources, and EOP review tools.

Mandatory Skills and Competencies

- Strong hands-on experience in Facets claims processing, including adjudication workflows, edits, pends, adjustments, and claim rework.
- Solid understanding of advantages administration, provider validation, claim pricing, and reimbursement logic within a payer environment.
- Preferred exposure to Blue plan workflows, including BlueCard, payment integrity, corrected claims, and claim edit management.

Qualifications

- Graduate (mandatory).
- 3+ years of experience in US healthcare payer claims processing.
- Experience with TriZetto Facets is mandatory.

📌 Claims Specialist (Chennai)
🏢 UST
📍 Chennai