Claims Ops SMEs with Facets experience

Claims Ops SMEs with Facets experience

Location: Remote

Contracct 12+ Months

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 highvolume claim scenarios and interpreting adjustment logic.
• Familiarity with configuration concepts such as:

o Benefit plan structures

• Pricing/reimbursement tables
• Provider and member configuration
• 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 datadriven 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).