Facets Developer

Job Title: FACETS Functional Consultant – Healthcare Payer

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Location: North Carolina -Hybrid

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Duration: Long Term Contract

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Job Summary

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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.

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Key Responsibilities

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FACETS Claims

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• Support FACETS claims configuration, processing, and adjudication.
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• Analyze claim pricing, benefits, provider reimbursement, and member eligibility impacts.
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• Investigate claim denials, pend conditions, adjustments, and processing issues.
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• Support professional, institutional, and dental claims processing.
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• Perform claims testing, validation, troubleshooting, and production support.
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• Enrollment, Membership, and Eligibility
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• Support member enrollment, subscriber and dependent maintenance, and demographic updates.
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• Manage eligibility processing, coverage effective dates, termination dates, and reinstatement activities.
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• Support group, subscriber, and membership setup and maintenance.
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FACETS Billing

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• Support premium billing, billing account setup, invoice generation, and billing cycle processing.
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• Analyze premium calculations based on member, coverage level, product, group, and effective dates.
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• Support payment processing, accounts receivable, credits, adjustments, and refunds.
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• Handle retroactive enrollment changes and related premium recalculations.
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• Perform billing reconciliation between enrollment, premiums, invoices, and payments.
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• Investigate and resolve billing and financial data discrepancies.
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• Benefits and Product Configuration
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• Configure and support healthcare products, plans, and benefit structures.
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• Support configuration of copays, deductibles, coinsurance, coverage limits, and eligibility rules.
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• Support product and benefit changes based on business requirements.
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• Provider Configuration
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• Coordinate with Claims and Benefits teams to resolve provider-related issues.
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FACETS Configuration

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• Analyze business requirements and translate them into FACETS functional configurations.
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• Support configuration across products, benefits, providers, claims rules, groups, plans, enrollment, and billing.
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• Perform impact analysis for FACETS configuration changes.
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• Participate in system enhancements, releases, upgrades, testing, and implementation activities.
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• Document business requirements, functional specifications, configuration changes, and test scenarios.
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Required Skills:

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• 8+ years of overall IT/Healthcare experience.
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• 5+ years of hands-on FACETS experience.
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• Strong experience in at least two or more core FACETS modules, with the ability to understand end-to-end payer workflows.
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• Healthcare payer or health insurance domain experience is required.
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• Strong hands-on experience with FACETS in a Healthcare Payer environment.
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• Experience with FACETS Claims and Claim Adjudication.
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• Experience with Enrollment, Membership, and Eligibility.
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• Experience with Premium Billing, Invoice Generation, Payment Processing, and Accounts Receivable.
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• Experience with Benefits, Products, Plans, and FACETS Configuration.
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• Knowledge of healthcare EDI/X12 transactions, especially 834, 837, 835, 270/271, and 276/277.
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• Strong understanding of healthcare payer business processes.
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• Strong SQL, data analysis, data validation, and reconciliation skills.
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