Claim Processor

Buzzworks Business Services; Chennai District, Bengaluru, Thiruvananthapuram; On-site; INR 450,000 - 650,000; Full time

Benefits offered by this job

Cab facility

Job summary

Buzzworks Business Services in Chennai, Tamil Nadu, invites an experienced Claim Processor to join our US Healthcare BPO team. You will perform end-to-end medical claims adjudication in the TriZetto FACETS platform for US payer clients, ensuring accuracy, compliance, and timely resolution.

The role requires 3+ years of FACETS experience, strong knowledge of benefits, pricing logic, and provider validation. You will handle pends, reprocessed claims, and workflow-driven processes within SLA

Qualifications

• FACETS claims processing with adjudication flow, edits, pends, adjustments, and rework.
• Knowledge of benefits, provider validation, claim pricing, and reimbursement logic in a payer environment.
• Experience in Healthcare BPM/BPO with SLA-driven operations.
• Exposure to Blue plan workflows including BlueCard and payment integrity.
• Strong analytical, problem-solving, and communication skills.

Responsibilities

• End-to-End Claims Adjudication: Process medical claims in TriZetto FACETS, including pend/suspend handling and reprocessing as required.
• Review member eligibility, benefits, claim type, provider details, and routing before final adjudication.
• Apply pricing methodologies within FACETS and resolve pricing/configuration discrepancies.
• Align workflow to submission/payment processes, including status review and escalation analysis.
• Analyze eligibility and pricing pends, resolve exceptions, and ensure timely handling of suspended/rejected claims.
• Process claims for BlueCard/shared administration workflows, including plan prefix and routing logic.
• Work within BPM environment, meeting SLAs, productivity targets, and quality standards.
• Support process improvement initiatives and operational excellence.

Skills

FACETS claims

adjudication flow

benefits validation

BlueCard workflows

SLA knowledge

analytical skills

communication

Tools

TriZetto FACETS

Availity Essentials

Job description

ring for our client a leading US based MNC in to Healthcare BPO division for Chennai, Bangalore & Trivanduram location for the Claim Processor position.

Position - Claim Processor

Experience - 3 + years

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.

Note

1 round will a be a F2F Discussion. 5 Days Work From Office and fully night shifts. Cab Facility is available.

With Regards,

Prason

[e-mail]

9841445277