Job Title: FACETS Functional Consultant Healthcare Payer
Location: Nearby Infosys Office (Hybrid Remote)
Duration: Long Term Contract with Possible Extension
Job Title: FACETS Functional Consultant Healthcare Payer
Job Summary
We are seeking an experienced FACETS Functional Consultant with strong expertise in the healthcare payer domain and hands-on experience across FACETS modules, including Claims, Enrollment, Membership and Eligibility, Billing, Benefits and Product Configuration, Provider Configuration, EDI/Interfaces, and Data Analysis.
The ideal candidate will have a strong understanding of end-to-end healthcare payer business processes and the ability to analyze business requirements, configure FACETS functionality, support EDI transactions and interfaces, perform data analysis using SQL, troubleshoot production issues, and coordinate with business and technical teams.
Key Responsibilities
FACETS Claims
- Support FACETS claims configuration, processing, and adjudication.
- Analyze claim pricing, benefits, provider reimbursement, and member eligibility impacts.
- Investigate claim denials, pend conditions, adjustments, and processing issues.
- Support professional, institutional, and dental claims processing.
- Perform claims testing, validation, troubleshooting, and production support.
Enrollment, Membership, and Eligibility
- Support member enrollment, subscriber and dependent maintenance, and demographic updates.
- Manage eligibility processing, coverage effective dates, termination dates, and reinstatement activities.
- Support group, subscriber, and membership setup and maintenance.
- Analyze enrollment transactions and resolve eligibility-related issues.
- Understand the impact of enrollment and eligibility changes on claims, benefits, and billing.
FACETS Billing
- Support premium billing, billing account setup, invoice generation, and billing cycle processing.
- Analyze premium calculations based on member, coverage level, product, group, and effective dates.
- Support payment processing, accounts receivable, credits, adjustments, and refunds.
- Handle retroactive enrollment changes and related premium recalculations.
- Perform billing reconciliation between enrollment, premiums, invoices, and payments.
- Investigate and resolve billing and financial data discrepancies.
Benefits and Product Configuration
- Configure and support healthcare products, plans, and benefit structures.
- Support configuration of copays, deductibles, coinsurance, coverage limits, and eligibility rules.
- Analyze the impact of benefit configuration on claims adjudication and member coverage.
- Support product and benefit changes based on business requirements.
Provider Configuration
- Support provider setup, maintenance, and provider demographic information.
- Configure and maintain provider networks and participation information.
- Support provider contract and reimbursement-related configuration.
- Investigate provider data issues impacting claims processing and reimbursement.
- Coordinate with Claims and Benefits teams to resolve provider-related issues.
FACETS Configuration
- Analyze business requirements and translate them into FACETS functional configurations.
- Support configuration across products, benefits, providers, claims rules, groups, plans, enrollment, and billing.
- Perform impact analysis for FACETS configuration changes.
- Participate in system enhancements, releases, upgrades, testing, and implementation activities.
- Document business requirements, functional specifications, configuration changes, and test scenarios.
FACETS Interfaces and EDI
- Support inbound and outbound FACETS interfaces and integrations with other healthcare systems.
- Work with healthcare EDI transactions, including:
- 834 Benefit Enrollment and Maintenance
- 837P Professional Claims
- 837I Institutional Claims
- 837D Dental Claims
- 835 Healthcare Claim Payment and Remittance
- 270/271 Eligibility Inquiry and Response
- 276/277 Claim Status Inquiry and Response
- 278 Healthcare Services Review and Authorization
- 820 Premium Payment
- 999 Implementation Acknowledgment
- TA1 Interchange Acknowledgment
- 277CA Claim Acknowledgment
- Analyze EDI transaction errors, acknowledgments, and data validation issues.
- Support interface testing, reconciliation, troubleshooting, and production issue resolution.
- Coordinate with internal teams and external trading partners.
Data Analysis and Reporting
- Write and analyze SQL queries to validate FACETS data.
- Perform data analysis across Claims, Enrollment, Eligibility, Billing, Benefits, and Provider data.
- Investigate data discrepancies and perform root cause analysis.
- Support data validation, reconciliation, and reporting activities.
- Troubleshoot production issues and coordinate resolution with business and technical teams.
Required Skills
- Strong hands-on experience with FACETS in a Healthcare Payer environment.
- Experience with FACETS Claims and Claim Adjudication.
- Experience with Enrollment, Membership, and Eligibility.
- Experience with Premium Billing, Invoice Generation, Payment Processing, and Accounts Receivable.
- Experience with Benefits, Products, Plans, and FACETS Configuration.
- Experience with Provider Setup, Provider Networks, and Provider Reimbursement.
- Knowledge of healthcare EDI/X12 transactions, especially 834, 837, 835, 270/271, and 276/277.
- Strong understanding of healthcare payer business processes.
- Strong SQL, data analysis, data validation, and reconciliation skills.
- Experience with testing, troubleshooting, production support, and root cause analysis.
- Strong communication and stakeholder management skills.
Preferred Skills
- Experience working with Medicare, Medicaid, Commercial, or ACA healthcare plans.
- Experience with HIPAA healthcare transactions.
- Knowledge of healthcare claims lifecycle and provider reimbursement.
- Experience with FACETS implementation, enhancement, migration, or upgrade projects.
- Experience working with business, development, QA, integration, and production support teams.
Experience Required
- 8+ years of overall IT/Healthcare experience.
- 5+ years of hands-on FACETS experience.
- Strong experience in at least two or more core FACETS modules, with the ability to understand end-to-end payer workflows.
- Healthcare payer or health insurance domain experience is required.
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