Claims & RCM operations,
run by a TriZetto-platform bench.
End-to-end resolution of complex inquiries — eligibility, authorization, payment, discrepancy, denial codes, and structured onshore tasking. Cognizant TriZetto partner bench, with an Epic-credentialed provider-side practice on the same Slack.
CARC
RARC literacy
270/278
Real-time
835
Verified
24×7
Coverage
Sample queue · illustrative
live opsWhat we own, end to end.
Managed end-to-end resolution of complex healthcare inquiries — six work threads on one accountable bench.
Patient Eligibility
Verification (270/271), COB / TPL reconciliation, member-plan-effective-date validation, and benefit-snapshot lookup at the point of inquiry.
Authorization Validation
Service-specific auth check, pre-cert and gold-card paths, retro-auth resolution, and policy-rule lookup tied to the claim (278 / FHIR).
Payment Details Review
Allowed amount, fee-schedule lookup, COB sequencing, capitation vs FFS reconciliation, and EOB-to-835 traceability.
Discrepancy Analysis
Deep-dive on what the provider expected vs. what the payer paid: contract, configuration, edit, modifier, member-cost-share, or fee-schedule mismatch.
Denials & Rejections
Code-level CARC / RARC explanation, root cause, and the exact corrective action the next claim needs to clear cleanly.
Strategic Tasking
Structured escalation to onshore policy, clinical, and configuration SMEs so unresolved claims stay in motion rather than aging in a queue.
Key activities.
Each piece of work is a structured pattern, not a screen-grab guess. Junior analysts learn the pattern; senior analysts catch the exceptions.
Query Resolution
We investigate multifaceted auth, denial, billing, and payment queries by running a deep-dive across the full claim history. Member coverage, prior-auth, contract, edit history, payment posting, and adjustments are reviewed together so the answer is complete the first time.
Payment Tracking
Real-time payment status updates verified against the 835 and the payer's ledger — not relayed from a stale screen. Providers and members get one accurate answer; the audit team gets the trail.
Denial Management
For every denial or rejection, we surface the actual code, the human-readable reason, and the actionable next step for resubmission. Generic "denied, see EOB" is not acceptable — staff convert it into a corrective playbook tied to the claim.
Onshore Tasking
When a claim hits policy nuance, clinical edits, or contract-language ambiguity, we formulate a strategic inquiry and "task" it to onshore partners (US-based clinical, configuration, or policy SMEs) to expedite resolution rather than letting the claim age.
One claim, six stages, fully traceable.
Intake
Queue ingest from member, provider, or payer-internal channel. SLA clock starts.
Triage
Classify (eligibility / auth / billing / denial / payment), assign skill level, route.
Deep-Dive
Pull claim history, contract, member, auth, EOB / 835. Identify the real root cause.
Resolution / Task
Resolve in-flight or task to an onshore SME with a structured strategic inquiry.
Verify
Confirm payment update against 835. No relay of unverified data.
Close & Log
Audit-ready record: who, what, why, when. CSAT capture for member or provider.
The things your CFO and Compliance both want.
Revenue Delay Prevention
Every denial reason is identified at the code level and converted into an actionable resubmission step. No claim is left unaddressed.
Data Integrity
Payment updates are verified against the 835 before they're shared. The number you give a provider is the number on the EOB.
No Aging Queues
Tasked claims flow to the right onshore SME within hours, not days. Unresolved is a process, not a result.
Audit-Ready Trail
Every query keeps its full reasoning: who looked, what they decided, why. Internal audit and external regulators see one record.
TriZetto platform-certified. Provider-side aware.
Two things almost no payer-services partner can offer in the same engagement.
Cognizant TriZetto Partner
- Facets configuration & customization
- QNXT operations & upgrades
- NetworX Pricer
- CareAdvance configurators
Payer-Ops Certifications
- CPC, CPB, CPMA (AAPC)
- CCS (AHIMA)
- Six Sigma Green Belt
- ITIL v4 Foundation
Provider-Side Bench
- Epic-credentialed analysts on hand
- Hospital RCM background
- Workday Financials literacy
- Real interop muscle, not slides
Where this connects to your provider arm
Same bench. Other end of the claim.
Many of the denial root causes we see on the payer side originate in the provider's EHR — Epic charge capture, missing modifiers, MyChart message routing, Hyperdrive sign-on glitches. Our 180+ Epic-credentialed analysts work the other end of the same wire. That's why our denial-resolution patterns close cleanly on resubmission instead of looping.
180+
Epic-Credentialed
84+
Workday-Certified
24×7
Operations
3
Delivery Centers
The Bench
Where claims credibility starts
Cognizant TriZetto partner program. Epic-credentialed provider-side bench. Gartner-recognized product. KLAS Customer Rated.
Certifications that show up in audits
What we sign with before we touch your member, provider, or claims data.
“The difference was the deep-dive. Every claim came back with the actual denial code, the actual cause, and the actual next step — not a stack of opaque rejections. Our recovery pattern tightened quickly, and our auditors stopped flagging the queue.”
Director, Claims Operations
Top-10 National Health Plan · Anonymized; named reference available under mutual NDA
Let's talk about your queue.
Bring your aged-denial bucket, your toughest payer-rule edge cases, or your hardest-to-reconcile payment queue. We'll walk through the resolution pattern on real claims.