Healthcare Claims Associates (Facets Exp Required)

UST; Taguig; Presencial; PHP 600 000 - 1 000 000; Tempo integral

Resumo da oferta

UST in the Philippines is seeking a Claims Processor to perform accurate, compliant, end-to-end medical claims adjudication within the TriZetto Facets platform for a U.S. healthcare payer.

Operating in a BPM environment, you will support pended, exception, corrected, and reprocessed claims while ensuring proper application of benefits, pricing logic, provider validation, and payer policies. You will participate in workflow management, review eligibility, workflow status, and COB/TPL scenarios,

Qualificações

• Graduate degree required.
• 5+ years of experience in U.S. healthcare payer claims processing.
• TriZetto Facets experience is mandatory.
• Experience in BPM/shared services/offshore operations preferred.

Responsabilidades

• End-to-End Claims Adjudication within TriZetto Facets.
• Review eligibility, benefit coverage, provider data, and routing prior to adjudication.
• Apply pricing methodologies and ensure compliance with HIPAA and payer policies.
• Handle pends, reprocessing, and automation workflows within BPM guidelines.

Formação académica

Graduate degree

Ferramentas

Availity Essentials

Coding references

Descrição da oferta de emprego

Role Description

Role Summary
The Claims Processor is responsible for performing accurate, compliant, and end-to-end medical claims adjudication within the TriZetto Facets platform for a U.S. healthcare payer. Operating within a Business Process Management (BPM) environment, the role supports claims processing activities including pended, exception, corrected, and reprocessed claims while ensuring proper application of benefits, pricing logic, provider validation, payer policies, quality standards, productivity targets, and SLA requirements.

Key Responsibilities

End-to-End Claims Adjudication

Process medical claims within the TriZetto Facets Claims module, including adjudication, pend management, suspensions, corrected claims, and reprocessing activities.
Review member eligibility, benefit coverage, provider information, claim type, and routing requirements prior to adjudication.
Validate and apply:
Deductibles, copayments, and coinsurance
Covered and non-covered services
Authorization and referral requirements
Apply pricing methodologies including:
Fee schedule-based pricing
Institutional reimbursement methodologies
Contractual payment rules
Identify and resolve discrepancies related to benefits, pricing configurations, and claim setup issues.
Execute processing activities in accordance with BPM workflows, operational guidelines, and productivity standards.

Workflow & Claims Resolution
Support claim handling across submission, adjudication, payment, and rework workflows.
Review claim status, EOPs, corrected claims, and COB/TPL scenarios.
Investigate and resolve:
Eligibility-related pends
Benefit and pricing validation issues
Provider and routing exceptions
Manage suspended, rejected, and rework claims within required turnaround times.
Process claims involving BlueCard and shared administration workflows, including:
Plan prefix identification
Home and Host plan coordination
Out-of-area claim processing
Maintain compliance with productivity targets, queue management requirements, turnaround time expectations, and SLAs.

Coding & Compliance
Validate medical coding and billing elements using:
ICD-10
CPT
HCPCS
DRG standards
Ensure compliance with payer guidelines, HIPAA regulations, documentation standards, and internal control requirements.
Participate in quality audits, validation activities, and defect prevention initiatives.
Support continuous improvement efforts focused on claims accuracy and operational efficiency.

Tools & Systems
TriZetto Facets (Claims, Workflow, Benefits, and Pricing modules)
Availity Essentials or equivalent eligibility and claim servicing platforms
Coding references, payment policy tools, and EOP review applications

Mandatory Skills & Competencies
Strong hands-on experience in TriZetto Facets Claims processing.
Solid understanding of:
Claims adjudication workflows
Claims edits and pends
Claims adjustments and rework
Benefits administration
Provider validation
Claims pricing and reimbursement methodologies
Exposure to BlueCard/Blue Plan workflows preferred.
Knowledge of:
Payment integrity concepts
Corrected claims processing
Claim edit management
Understanding of BPM operations, workflow management, quality frameworks, productivity metrics, and SLA-driven delivery models.
Strong analytical, problem-solving, attention-to-detail, and process adherence skills.

Qualifications

Graduate degree required
5+ years of experience in U.S. Healthcare Payer Claims Processing
TriZetto Facets experience is mandatory
Experience working within a BPM, shared services, or offshore operations environment preferred

Skills
FACETS, Claims Management, Provider Data Management, HIPAA