Associate III - BPM- Claim Processor

At UST, we help the world’s best organizations grow and succeed through transformation. Bringing together the right talent, tools, and ideas, we work with our client to co-create lasting change. Together, with over 30,000 employees in 30+ countries, we build for boundless impact—touching billions of lives in the process.

Visit us at . Summary: UST is looking for…. 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 Tri. Zetto 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.

Key Responsibilities

End-to-End Claims Adjudication Process medical claims in Tri. Zetto 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 Blue. Card 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 Tri. Zetto 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. 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 Blue. Card, payment integrity, corrected claims, and claim edit handling.

Strong analytical, problem-solving, and communication skills.

Qualifications

Graduate (Mandatory). 5+ years of experience in US Healthcare Payer Claims Processing and Healthcare BPM Operations. Experience in Tri. Zetto FACETS is mandatory. Experience working in a Healthcare BPM/BPO environment is preferred. What you need: BTech/ MCA/ BCA/Msc IT/Bsc IT Required Skills: HIPAA, ICD-10-CM, Claims Management, Provider Data Management What you need: What we believe : We’re proud to embrace the same values that have shaped UST since the beginning.

Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion and to place people at the centre of everything we do. Humility: We will listen, learn, be empathetic and help selflessly in our interactions with everyone.

Humanity: Through business, we will better the lives of those less fortunate than ourselves. Integrity: We honour our commitments and act with responsibility in all our relationships. Equal Employment Opportunity Statement UST is an Equal Opportunity Employer. We believe that no one should be discriminated against because of their differences, such as age, disability, ethnicity, gender, gender identity and expression, religion, or sexual orientation.

All employment decisions shall be made without regard to age, race, creed, colour, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law.

UST reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

• To support and promote the values of UST.
• Comply with all Company policies and procedures