Claims Associate III - BPM

Role Summary

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

End-to-End Claims Adjudication

• 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.

Workflow & Claims Resolution

• 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.

Coding & Compliance

• Validate medical coding and billing elements using:
  • ICD-10
  • CPT
  • HCPCS
  • DRG standards
• Ensure compliance with payer guidelines, HIPAA regulations, documentation standards, and internal control requirements.
• Participate in quality audits, validation activities, and defect prevention initiatives.
• Support continuous improvement efforts focused on claims accuracy and operational efficiency.

Tools & Systems

• TriZetto Facets (Claims, Workflow, Benefits, and Pricing modules)
• Availity Essentials or equivalent eligibility and claim servicing platforms
• Coding references, payment policy tools, and EOP review applications

Mandatory Skills & Competencies

• Strong hands-on experience in TriZetto Facets Claims processing.
• Solid understanding of:
  • Claims adjudication workflows
  • Claims edits and pends
  • Claims adjustments and rework
  • Benefits administration
  • Provider validation
  • Claims pricing and reimbursement methodologies
• Exposure to BlueCard/Blue Plan workflows preferred.
• Knowledge of:
  • Payment integrity concepts
  • Corrected claims processing
  • Claim edit management
• Understanding of BPM operations, workflow management, quality frameworks, productivity metrics, and SLA-driven delivery models.
• Strong analytical, problem-solving, attention-to-detail, and process adherence skills.

Qualifications

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