Associate III - BPM
UST Global · Thiruvananthapuram · onsite · Posted 29d ago
Undisclosed3–5 yrsfulltimeSourced from
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About this role
Job Summary
Responsibilities
Coding Compliance
Tools Systems
Mandatory Skills Competencies
Qualifications
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.
Claims Processor - US Healthcare Payer (FACETS) | BPM Role Summary. Claims Processors will support US Healthcare Payer and BPM operations, responsible for accurate and compliant end-to-end medical claims adjudication within the TriZetto FACETS platform. The role requires strong knowledge of benefits, pricing logic, provider validation, and payer rules while operating in a workflow-driven environment. The individual will manage pended, exception, and reprocessed claims with adherence to productivity, quality, SLA, and compliance requirements.
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.
- Workflow Alignment BPM Operations: 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, and provider or routing-related exceptions.
- Ensure timely handling of suspended claims, rejected claims, and claims requiring rework or escalation.
- Process claims aligned to BlueCard and shared administration workflows, including plan prefix identification, routing logic, Home and Host plan considerations, and out-of-area claim handling.
- Work within a Healthcare BPM environment, adhering to defined SLAs, productivity targets, quality standards, and operational governance requirements.
- Support continuous process improvement initiatives and operational excellence programs.
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 expectations, BPM operational standards, and internal audit/control requirements.
Tools Systems
- TriZetto FACETS - Claims, Workflow, Pricing, and Benefits-linked Adjudication.
- Availity Essentials or equivalent tools for eligibility, benefits, claim status, and servicing activities.
- Coding and billing references, payment policy references, and EOP review tools.
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.
- Experience working in a Healthcare BPM/BPO environment with exposure to SLA-driven operations and workflow management.
- Preferred exposure to Blue plan workflows including BlueCard, payment integrity, corrected claims, and claim edit handling.
- Strong analytical and problem-solving skills.
Qualifications
- Graduate (Mandatory).
- 5+ years of experience in US Healthcare Payer Claims Processing and Healthcare BPM Operations.
- Experience in TriZetto FACETS is mandatory.
- Experience working in a Healthcare BPM/BPO environment is 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.
Sourced from naukri
Skills
Rejection Analysisworkflowsworkflow managementhcpcshipaaBpmProcess ImprovementAdjudicationProcessorInternal AuditSLAHealthcareCommunication SkillsoperationsAdministrationbpocomplianceClaims Processing
About UST
UST Global
IT Services & Consulting
14.0k+
employees
1999
27 years old
Aliso Viejo, California
US
₹12.9L PA avg
Avg at UST
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UST helps the world's best organizations succeed through digital transformation, crafting disruptive solutions and strategies bringing our clients vision to life.
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