Senior Claims Adjudication Specialist - TriZetto Facets Expert

UST; Taguig; On-site; PHP 800,000 - 1,200,000; Full time

Job summary

UST is seeking an experienced Claims Processor to perform end-to-end medical claims adjudication in the TriZetto Facets platform for a U.S. healthcare payer.

The role operates within a BPM environment and supports pend management, reprocessing, and eligibility validation while ensuring compliance with payer policies and SLAs. Responsibilities include reviewing member eligibility, applying pricing rules, resolving discrepancies, and ensuring accurate claims processing across submission,

Qualifications

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

Responsibilities

• End-to-End Claims Adjudication in TriZetto Facets module.
• Review eligibility, benefit coverage, and pricing prior to adjudication.
• Validate deductibles, copays, coinsurance, and coverage rules.
• Apply pricing methodologies including fee schedules and contract rules.
• Identify and resolve discrepancies in benefits and pricing configurations.
• Maintain adherence to BPM workflows, guidelines, and SLAs.
• Process claims in submission, adjudication, payment and rework stages.
• Manage suspended, rejected, and rework claims within turnaround times.

Skills

TriZetto Facets processing

Claims workflows

Provider validation

HIPAA compliance

Analytical skills

Education

Graduate degree

Tools

TriZetto Facets

Availity Essentials

Job description

UST is seeking an experienced Claims Processor to perform end-to-end medical claims adjudication in the TriZetto Facets platform for a U.S. healthcare payer.

The role operates within a BPM environment and supports pend management, reprocessing, and eligibility validation while ensuring compliance with payer policies and SLAs. Responsibilities include reviewing member eligibility, applying pricing rules, resolving discrepancies, and ensuring accurate claims processing across submission,