Other Service Line Bps Hc Sd

MAX VENDOR RATE; #### -- REMOTE

Key Responsibilities
Mass Claims Adjustment Execution
Review and validate incoming requests for mass claim adjustments (typically 50+ affected claims), ensuring completeness, accuracy, and alignment with internal guidelines.
Treat each adjustment request as a mini project, managing intake, validation, execution steps, and closure.
Create and manage templates for adjustments within the Facets UI, including benefit, pricing, and configuration touchpoints as needed.
Process adjustments through Azure DevOps, ensuring traceability, documentation, and timely updates.
Perform root cause validation and reconcile claim subsets to verify that the adjustment request aligns with actual claim conditions.
Claims Subject Matter Expertise
Apply advanced knowledge of Facets claims processing, including benefit applications, pricing tables, accumulators, provider configuration, and backend system behavior.
Execute claim adjustments manually and systemically with a deep understanding of how downstream systems and configuration impact results.
Identify potential configuration issues, trends, and systemic defects that contribute to mass adjustment demand.
Data Analysis & Validation
Analyze large data sets to identify impacted claims, validate request criteria, and ensure accuracy before and after adjustment execution.
Utilize data tools to confirm that the adjustment logic matches expected claim scenarios and business requirements.
Produce clear, logically structured summaries outlining root causes, validation results, and historical trends to reduce repetitive requests.
Stakeholder Communication & Collaboration
Communicate effectively with requesters, markets, operations teams, and leadership to obtain approvals, clarify requirements, and provide post adjustment summaries.
Explain complex claims scenarios, configuration logic, and adjustment rationales in a clear, business friendly way.
Partner closely with automation teams to identify process improvement and automation opportunities, reducing manual ticket submissions.
Operational Governance & Quality Control
Ensure all adjustments follow internal standards, quality expectations, and compliance requirements.
Participate in trend analysis discussions and continuous process improvement initiatives across claims operations.
Support documentation updates, workflow refinements, and knowledge transfer within the MCA team.


Required Skills & Qualifications
Technical & Functional Expertise
Must have: Advanced Facets claims processing experience, including claim lifecycle, pricing rules, benefit application logic, and backend workflows.
Strong understanding of claim adjustment processes and downstream operational impacts.
Experience validating high volume claim scenarios and interpreting adjustment logic.
Familiarity with configuration concepts such as:
o Benefit plan structures
o Pricing/reimbursement tables
o Provider and member configuration
o Edit logic and adjudication rules
Data & Analytical Skills
Ability to analyze large claims datasets using Excel or similar tools.
Skilled in validating subsets of claims against request criteria and identifying discrepancies.
Ability to summarize root causes and trends using data driven analysis.
Communication & Collaboration
Strong written and verbal communication skills, able to translate technical claims logic into clear business explanations.
Experience partnering with operations teams, requesters, markets, or other business units.
Ability to manage multiple adjustment initiatives simultaneously with attention to detail and accuracy.
Tools & Systems
Facets (required) deep operational expertise.
Azure DevOps (preferred) for request tracking and workflow management.
Microsoft Excel and data validation tools (required).