Associate III - BPM- Claim Processor

About the role

Claims Processor – US Healthcare Payer (FACETS) | BPM Role Summary 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.

What you'll do

• End-to-End Claims Adjudication Process medical claims in TriZetto FACETS Claims module, including review, adjudication, pend/suspend handling, corrected claims
• 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…
• Workflow Alignment & BPM Operations Support claim handling aligned to claim submission and payment workflows, including claim status review, corrected claims
• Analyze and resolve eligibility-related pends, pricing and benefit validation pends, and provider or routing-related exceptions

What you need

• 3–5 yrs of experience
• Claims processing
• Medical coding
• Internal audit
• Compliance
• BCA or MCA or B.Tech or B.E. or B.Sc or M.Sc