Associate III - BPM- Claim Processor

Claims Processor – US Healthcare Payer (FACETS) | BPM
Experience: 3 to 5 Years
Domain: US Healthcare Payer / Healthcare BPM
Employment Type: Full-Time
Location : Bangalore, Chennai, Trivandrum
Salary as per industry standards
Key Responsibilities
1. Claims Processing & Adjudication
Process medical claims end-to-end using the TriZetto FACETS Claims module.
Review claims for member eligibility, benefits, provider details, claim type, and routing.
Handle pended, suspended, rejected, corrected, adjusted, and reprocessed claims.
Apply deductibles, copayments, coinsurance, coverage limitations, authorization, and referral rules.
Investigate claim discrepancies and resolve adjudication errors.
2. Claims Pricing & Benefits Validation
Apply fee schedules, contractual payment rules, and institutional reimbursement methodologies.
Validate provider contracts, benefit plans, and reimbursement rules.
Identify and resolve pricing discrepancies and benefit configuration issues.
Ensure accurate claim payments in accordance with payer guidelines.
3. Workflow & Healthcare BPM Operations
Review claim status, Explanation of Payment (EOP), and payment-related exceptions.
Handle Coordination of Benefits (COB), Third-Party Liability (TPL), and corrected claims.
Analyze eligibility, pricing, provider-related, and routing exceptions.
Support BlueCard and Blue Plan workflows, including Home and Host plan routing and out-of-area claims, where applicable.
Meet defined productivity, accuracy, quality, and SLA targets in a BPM/BPO environment.
4. Coding, Compliance & Quality
Validate coding and billing information using ICD-10-CM, CPT, HCPCS, and DRG standards, as applicable.
Follow HIPAA regulations, payer policies, documentation requirements, and internal quality controls.
Maintain accurate processing records and support audits and continuous improvement initiatives.
Mandatory Skills
Hands-on experience with TriZetto FACETS Claims processing.
US Healthcare Payer Claims Processing.
Medical Claims Adjudication and Claims Management.
Understanding of benefits, eligibility, provider validation, and claims pricing.
Knowledge of HIPAA and ICD-10-CM.
Experience handling claim edits, pends, adjustments, rework, and exceptions.
Strong analytical, problem-solving, and communication skills.
Preferred Skills
Healthcare BPM/BPO operations.
BlueCard and Blue Plan claims processing.
COB/TPL, corrected claims, and payment integrity.
Provider Data Management.
CPT, HCPCS, and DRG coding and billing standards.
Availity Essentials or equivalent healthcare payer tools.
Experience working with SLA-driven claims workflows.
Educational Qualifications
Graduation is mandatory.
Preferred qualifications: B.Tech, B.E., BCA, B.Sc. IT, M.Sc. IT, or MCA.
Experience Requirements
Minimum 3+ years of experience in US Healthcare Payer Claims Processing and Healthcare BPM operations.
Hands-on experience with TriZetto FACETS is mandatory.
Experience in a healthcare BPM/BPO environment is preferred.

Work arrangement
No