Associate III - BPM

UST; Thiruvananthapuram; On-site; INR 5,764,000 - 8,646,000; Full time

Job summary

UST is hiring for a Claims Processor – US Healthcare Payer (FACETS). The role focuses on end-to-end adjudication within the TriZetto FACETS platform, applying benefits, pricing logic, and payer rules.

You will handle pended, exception, and reprocessed claims while maintaining SLA, accuracy, and compliance in a BPM-driven environment, collaborating with cross-functional teams to ensure correct claim outcomes.

Qualifications

• Graduate (Mandatory).
• 5+ years of experience in US Healthcare Payer Claims Processing.
• Experience with TriZetto FACETS is mandatory.
• Experience in Healthcare BPM/BPO environments preferred.

Responsibilities

• End-to-End Claims Adjudication in TriZetto FACETS Claims module, including review, adjudication, pend/suspend handling, and reprocessing.
• Review member eligibility, benefits, claim type, provider details, and claim routing before adjudication.
• Apply pricing methodologies, deductibles, copays, coinsurance, and reimbursement logic.
• Identify and resolve discrepancies in pricing configuration and claim setup.
• Support workflows aligned to submission, payment, and escalation processes.

Skills

HIPAA

ICD-10-CM

Claims Management

Provider Data Management

Education

Graduate

Tools

TriZetto FACETS

Availity Essentials

Job description

Role Description

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.

Key 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 Exposure

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, problem-solving, and communication 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.

Skills

HIPAA, ICD-10-CM, Claims Management, Provider Data Management