Non Voice Claims Reps (Facets Exp Required)

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

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

• 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.

• 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.

Qualifications:

• High school graduate or college undergraduate

• At least 2 years of experience in U.S. Healthcare Payer Claims Processing

• Facets platform experience required