Facets Claims Examiner / Processor

Healthcare IS; United States; On-site; USD 55,000 - 85,000; Full time

Job summary

Healthcare IS is seeking experienced Facets Claims Examiners to support a large payer with processing complex healthcare claims operations. The role requires hands-on processing within the Facets platform, including COB claims and interpretation of benefits and payment rules.

Ideal candidates will have strong attention to detail, the ability to work in a production-driven environment, and clear written and verbal communication.

Qualifications

• Hands-on experience as a Facets Claims Examiner with advanced Facets knowledge.
• Experience processing Coordination of Benefits (COB) claims.
• Ability to analyze claim details and determine accurate processing decisions.
• Clear written and verbal communication in a deadline-driven environment.

Responsibilities

• Manually review, evaluate, and process healthcare claims within the Facets platform.
• Research and resolve complex claim scenarios requiring interpretation of benefits and rules.
• Validate primary/secondary payer responsibility in COB claims.
• Identify discrepancies and document processing decisions.
• Escalate issues when additional review is required.
• Collaborate with team and client stakeholders to support timely resolution.

Skills

Facets Claims Processing

COB processing

Claim analysis

Attention to detail

Communication skills

Production environment

Job description

We are seeking experienced Facets Claims Examiners / Processors to support a large payer with processing complex healthcare claims operations. This role is ideal for claims professionals with strong Facets expertise, sound judgment, and demonstrated experience manually reviewing and processing claims that require detailed analysis and interpretation.

Key Responsibilities

• Manually review, evaluate, and process healthcare claims within the Facets platform.
• Research and resolve complex claim scenarios requiring interpretation of benefits, plan provisions, payment rules, and supporting documentation.
• Process claims involving Coordination of Benefits (COB), including validation of primary and secondary payer responsibility.
• Identify claim discrepancies, determine appropriate resolution, and document claim-processing decisions accurately.
• Apply established policies, procedures, and client-specific requirements while meeting quality and productivity expectations.
• Escalate claims issues, system concerns, or processing trends when additional review is required.
• Collaborate with team members and client stakeholders to support timely and accurate claim resolution.

Required Qualifications

• Must have current and hands-on experience as a Facets Claims Examiner, with advanced working knowledge of Facets claims processing (not Configuration).
• Demonstrated experience manually processing healthcare claims, including complex and exception-based scenarios.
• Experience processing Coordination of Benefits (COB) claims.
• Ability to analyze claim details, benefit information, and supporting documentation to make accurate processing decisions.
• Strong attention to detail, critical-thinking skills, and commitment to quality.
• Ability to work effectively in a production-oriented, deadline-driven environment.
• Clear written and verbal communication skills.
• Prior experience with ITS Home and Host claim processing, a plus.