Medical Claims Adjudication Specialist

UST; Taguig; On-site; PHP 391,000 - 725,000; Full time

Job summary

UST is seeking a Claims Processor in the Philippines to adjudicate U.S. healthcare payer claims within the TriZetto Facets platform.

The role operates in a BPM environment, supporting pended, pending, corrected, and reprocessed claims while ensuring accurate benefits application, pricing logic, provider validation, and adherence to SLAs. Responsibilities include reviewing eligibility, coverage, and routing, applying deductibles and coinsurance, and ensuring compliance with payer policies.

Qualifications

• Experience in U.S. Healthcare Payer Claims Processing.
• Facets platform experience required.
• High school graduate or college undergraduate.

Responsibilities

• Process medical claims within TriZetto Facets Claims module, including adjudication, pend management, suspensions, corrected claims, and reprocessing.
• Review member eligibility, benefit coverage, provider information, claim type, and routing requirements prior to adjudication.
• Validate deductibles, copayments, coinsurance, covered/non-covered services, and authorization/referral requirements.
• Apply pricing methodologies including fee schedule-based pricing, institutional reimbursement, and contractual payment rules.
• Identify and resolve discrepancies related to benefits, pricing configurations, and claim setup issues.
• Execute processing activities in accordance with BPM workflows and SLA requirements.
• Support claim handling across submission, adjudication, payment, and rework workflows.
• Review claim status, EOPs, corrected claims, and COB/TPL scenarios.
• Investigate eligibility-related pends and pricing validation issues.

Education

High school graduate or college undergraduate

Tools

TriZetto Facets

Job description

UST is seeking a Claims Processor in the Philippines to adjudicate U.S. healthcare payer claims within the TriZetto Facets platform.

The role operates in a BPM environment, supporting pended, pending, corrected, and reprocessed claims while ensuring accurate benefits application, pricing logic, provider validation, and adherence to SLAs. Responsibilities include reviewing eligibility, coverage, and routing, applying deductibles and coinsurance, and ensuring compliance with payer policies.