US Healthcare Claims Sr. Associates (Facets Exp a plus)

UST; Taguig; On-site; PHP 3,141,000 - 5,025,000; Full time

Job summary

UST is seeking a Claims Processor to adjudicate medical claims end-to-end within the TriZetto Facets system for a U.S. healthcare payer.

The role operates in a BPM environment to support claims processing activities while meeting quality standards, productivity targets, and SLA requirements. Responsibilities include adjudication, eligibility review, applying deductibles and pricing rules, and resolving discrepancies.

Qualifications

• 5+ years of experience in U.S. Healthcare Payer Claims Processing.
• TriZetto Facets experience is an advantage.
• Experience working within BPM/shared services or offshore operations preferred.
• High school graduate or college undergraduate.

Responsibilities

• Process medical claims within TriZetto Facets, including adjudication and reprocessing.
• Review eligibility, benefits, and provider information prior to adjudication.
• Apply deductibles, coinsurance, copayments, and pricing rules.
• Identify and resolve discrepancies in benefits and claim setup.
• Ensure processing adheres to BPM workflows, SLAs, and productivity standards.
• Support claim handling across submission, adjudication, payment, and rework.
• Investigate eligibility-related pends and routing exceptions.

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

• 5+ years of experience in U.S. Healthcare Payer Claims Processing

• TriZetto Facets experience an advantage

• Experience working within a BPM, shared services, or offshore operations environment preferred