Facets Developer

Career Soft Solutions Inc; Durham (NC); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Career Soft Solutions Inc seeks an experienced FACETS Functional Consultant with strong healthcare payer domain expertise and hands-on experience across FACETS modules, including Claims, Enrollment, Membership and Eligibility, Billing, Benefits and Provider Configuration. This is a long-term contract in North Carolina with hybrid work options.

Responsibilities include analyzing business requirements, translating them into FACETS configurations, supporting testing and production activities, and

Qualifications

• 8+ years of IT/Healthcare experience.
• 5+ years hands-on FACETS experience.
• Strong experience in multiple FACETS modules and end-to-end payer workflows.
• Healthcare payer or health insurance domain experience.

Responsibilities

• Support FACETS Claims configuration, processing, and adjudication.
• Analyze pricing, benefits, and eligibility impacts.
• Investigate denials, pend conditions, and processing issues.
• Support enrollment, billing, and premium reconciliation processes.
• Configure and support healthcare products, plans, and benefit structures.
• Coordinate with Claims and Benefits teams to resolve provider issues.

Skills

FACETS

SQL

Data analysis

Job description

Job Title: FACETS Functional Consultant – Healthcare Payer

Location: North Carolina -Hybrid

Duration: Long Term Contract

Job Summary

We are seeking an experienced FACETS Functional Consultant with strong expertise in the healthcare payer domain and hands-on experience across FACETS modules, including Claims, Enrollment, Membership and Eligibility, Billing, Benefits and Product Configuration, Provider Configuration, EDI/Interfaces, and Data Analysis.

Key Responsibilities

FACETS Claims

• Support FACETS claims configuration, processing, and adjudication.
• Analyze claim pricing, benefits, provider reimbursement, and member eligibility impacts.
• Investigate claim denials, pend conditions, adjustments, and processing issues.
• Support professional, institutional, and dental claims processing.
• Perform claims testing, validation, troubleshooting, and production support.
• Enrollment, Membership, and Eligibility
• Support member enrollment, subscriber and dependent maintenance, and demographic updates.
• Manage eligibility processing, coverage effective dates, termination dates, and reinstatement activities.
• Support group, subscriber, and membership setup and maintenance.
• Support premium billing, billing account setup, invoice generation, and billing cycle processing.
• Analyze premium calculations based on member, coverage level, product, group, and effective dates.
• Support payment processing, accounts receivable, credits, adjustments, and refunds.
• Handle retroactive enrollment changes and related premium recalculations.
• Perform billing reconciliation between enrollment, premiums, invoices, and payments.
• Investigate and resolve billing and financial data discrepancies.
• Benefits and Product Configuration
• Configure and support healthcare products, plans, and benefit structures.
• Support configuration of copays, deductibles, coinsurance, coverage limits, and eligibility rules.
• Support product and benefit changes based on business requirements.
• Provider Configuration
• Coordinate with Claims and Benefits teams to resolve provider-related issues.

FACETS Configuration

• Analyze business requirements and translate them into FACETS functional configurations.
• Support configuration across products, benefits, providers, claims rules, groups, plans, enrollment, and billing.
• Perform impact analysis for FACETS configuration changes.
• Participate in system enhancements, releases, upgrades, testing, and implementation activities.
• Document business requirements, functional specifications, configuration changes, and test scenarios.

Required Skills:

• 8+ years of overall IT/Healthcare experience.
• 5+ years of hands-on FACETS experience.
• Strong experience in at least two or more core FACETS modules, with the ability to understand end-to-end payer workflows.
• Healthcare payer or health insurance domain experience is required.
• Strong hands-on experience with FACETS in a Healthcare Payer environment.
• Experience with FACETS Claims and Claim Adjudication.
• Experience with Enrollment, Membership, and Eligibility.
• Experience with Premium Billing, Invoice Generation, Payment Processing, and Accounts Receivable.
• Experience with Benefits, Products, Plans, and FACETS Configuration.
• Knowledge of healthcare EDI/X12 transactions, especially 834, 837, 835, 270/271, and 276/277.
• Strong understanding of healthcare payer business processes.
• Strong SQL, data analysis, data validation, and reconciliation skills.