Associate III - BPM- Claim Processor

About The Job:
Claims Processor – US Healthcare Payer (FACETS)

• Claims Processors will support US Healthcare Payer and BPM operations, responsible for accurate and compliant end-to-end medical claims adjudication within the TriZetto FACETS platform.
• The role requires strong knowledge of benefits, pricing logic, provider validation, and payer rules while operating in a workflow-driven environment.
• The individual will manage pended, exception, and reprocessed claims with adherence to productivity, quality, SLA, and compliance requirements.

Essential Job Functions:
End-to-End Claims Adjudication

• Process medical claims in TriZetto FACETS Claims module, including review, adjudication, pend/suspend handling, corrected claims, and reprocessing as required.
• Review member eligibility, benefits, claim type, provider details, and claim routing before final adjudication.
• Ensure correct application of:
  • Deductibles, copay, and coinsurance
  • Covered vs. non-covered services
  • Authorization and referral requirements
• Apply appropriate pricing methodologies within FACETS, including:
  • Fee schedule-based pricing
  • Institutional reimbursement logic
  • Contractual payment rules
• Identify and resolve discrepancies related to pricing configuration, benefit-plan interaction, and claim setup issues.

Workflow Alignment & BPM Operations

• Support claim handling aligned to claim submission and payment workflows, including claim status review, corrected claims, EOP understanding, COB/TPL handling, and suspension/rejection analysis.
• Analyze and resolve eligibility-related pends, pricing and benefit validation pends, and provider or routing-related exceptions.
• Ensure timely handling of suspended claims, rejected claims, and claims requiring rework or escalation.
• Process claims aligned to BlueCard and shared administration workflows, including plan prefix identification, routing logic, Home and Host plan considerations, and out-of-area claim handling.
• Work within a Healthcare BPM environment, adhering to defined SLAs, productivity targets, quality standards, and operational governance requirements.
• Support continuous process improvement initiatives and operational excellence programs.

Coding & Compliance

• Validate coding and billing elements using ICD-10, CPT, HCPCS, and DRG-related billing standards as applicable to payer claims processing.
• Ensure compliance with payer guidelines, HIPAA regulations, documentation expectations, BPM operational standards, and internal audit/control requirements.

Tools & Systems Exposure

• TriZetto FACETS – Claims, Workflow, Pricing, and Benefits-linked Adjudication.
• Availity Essentials or equivalent tools for eligibility, benefits, claim status, and servicing activities.
• Coding and billing references, payment policy references, and EOP review tools.

Qualifications:
Mandatory Skills & Competencies

• Strong hands-on experience in FACETS Claims processing with knowledge of adjudication flow, edits, pends, adjustments, and rework.
• Good understanding of benefits, provider validation, claim pricing, and reimbursement logic in a payer environment.
• Experience working in a Healthcare BPM/BPO environment with exposure to SLA-driven operations and workflow management.
• Preferred exposure to Blue plan workflows including BlueCard, payment integrity, corrected claims, and claim edit handling.
• Strong analytical, problem-solving, and communication skills.

Education

• Graduate (Mandatory).
• 5+ years of experience in US Healthcare Payer Claims Processing and Healthcare BPM Operations.
• Experience in TriZetto FACETS is mandatory.
• Experience working in a Healthcare BPM/BPO environment is preferred.
• BTech / MCA / BCA / MSc IT / BSc IT

Required Skills:

• HIPAA
• ICD-10-CM
• Claims Management
• Provider Data Management

How to Apply:Interested candidates are encouraged to respond/submit their updated resumes, and for additional job opportunities, please visitJobs In India – VARITE.

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About VARITE: VARITE is a global staffing and IT consulting company providing technical consulting and team augmentation services to Fortune 500 Companies in USA, UK, CANADA and INDIA. VARITE is currently a primary and direct vendor to the leading corporations in the verticals of Networking, Cloud Infrastructure, Hardware and Software, Digital Marketing and Media Solutions, Clinical Diagnostics, Utilities, Gaming and Entertainment, and Financial Services.

Equal Opportunity Employer:
VARITE is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based on race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, marital status, veteran status, or disability status.