Associate III - BPM

Job Summary

Claims Processor - US Healthcare Payer (Facets) | BPM Role Summary Claims Processors will support US healthcare payer claims operations and BPM-driven claims management processes. Responsible for accurate and compliant end-to-end medical claims adjudication within the TriZetto Facets platform, ensuring proper application of benefits, pricing logic, provider validation, and payer rules. The role operates within a highly workflow-driven BPM environment, handling pended, exception, and reprocessed claims while ensuring alignment between Facets system logic, claim data, and final payment outcomes with strong adherence to productivity, quality, SLA, and compliance expectations.

Responsibilities

• End-to-End Claims Adjudication: Process medical claims in TriZetto Facets Claims module, including review, adjudication, pend/suspend handling, corrected claims, and reprocessing as required.
• Review member eligibility, benefits, claim type, provider details, and claim routing before final adjudication.
• Ensure correct application of: Deductibles, copay, and coinsurance
• Covered vs. non-covered services
• Authorization and referral requirements
• Apply appropriate pricing methodologies within Facets, including: Fee schedule-based pricing
• Institutional reimbursement logic
• Contractual payment rules
• Identify and resolve discrepancies related to pricing configuration, benefit-plan interaction, and claim setup issues.
• BPM Workflow Operations: Execute healthcare claims processes in accordance with established BPM workflows, SLAs, quality standards, and operational KPIs.
• Support continuous process improvement initiatives to enhance claims accuracy, turnaround time, and operational efficiency.
• Monitor workflow queues, prioritize pending claims, and ensure timely completion of assigned work items.
• Collaborate with quality, training, and operations teams to drive process compliance and best practices.
• Maintain process documentation and support audit readiness activities.
• Workflow Alignment: Support claim handling aligned to claim submission and payment workflows, including claim status review, corrected claims, EOP understanding, COB/TPL handling, and suspension/rejection analysis.
• Analyze and resolve: Eligibility-related pends, Pricing and benefit validation pends, Provider or routing-related exceptions
• Ensure timely handling of suspended claims, rejected claims, and claims requiring rework or escalation.
• Process claims aligned to Blue plan workflows, including: BlueCard processing, Plan prefix identification and routing logic, Home and Host plan considerations, Out-of-area claim handling.
• Coding Compliance: Validate coding and billing elements using ICD-10, CPT, HCPCS, and DRG-related billing standards as applicable to payer claims processing.
• Ensure compliance with payer guidelines, HIPAA regulations, documentation standards, and internal audit requirements.
• Adhere to BPM operational governance, process controls, and quality assurance standards.

Tools and Systems

• TriZetto Facets - Claims, Workflow, Pricing, and Benefits Adjudication.
• Availity Essentials or equivalent tools for eligibility, benefits, and claim status verification.
• Coding and billing reference tools.
• Payment policy and EOP review tools.
• BPM workflow management and operational reporting tools (preferred).

Mandatory Skills & Competencies

• Strong hands-on experience in Facets Claims processing with knowledge of adjudication flow, edits, pends, adjustments, and rework.
• Good understanding of benefits, provider validation, claim pricing, and reimbursement logic in a payer environment.
• Knowledge of BPM operations, workflow management, SLA tracking, quality metrics, and continuous improvement practices.
• Preferred exposure to Blue plan workflows, including BlueCard, payment integrity, corrected claims, and claim edit handling.
• Strong analytical, problem-solving, and process-oriented mindset.

Qualifications

• Graduate (Mandatory).
• 5+ years of experience in US Healthcare Payer Claims Processing/BPM Operations.
• Experience in TriZetto Facets is mandatory.
• Experience working in a Healthcare BPM/BPO environment is highly preferred.

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.