Only W2- Facets Claims Adjustment Specialist

Key Responsibilities

Mass Claims Adjustment Execution

Claims Subject Matter Expertise

Data Analysis & Validation

Stakeholder Communication & Collaboration

Operational Governance & Quality Control

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

Data & Analytical Skills

Communication & Collaboration

Tools & Systems

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:

• 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 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).