Claim Processor

CLAIMS PROCESSOR – 1

(Sta. Ana Balibago Angeles City Pampanga Office)
Work Schedule: 8:30am-5:30pm
Salary Offer: 18, 000

Responsibilities:
➢ Review and analyze healthcare claims for accuracy, completeness, and adherence to contractual
agreements and regulatory guidelines.
➢ Verify member eligibility and benefits coverage for submitted claims.
➢ Evaluate medical documentation to assess the appropriateness of services rendered and coding
accuracy.
➢ Adjudicate claims accurately and efficiently within established turnaround times.
➢ Identify and investigate potential fraudulent or abusive billing practices.
➢ Communicate claim decisions, payment details, and denials to providers and members effectively.
➢ Collaborate with other departments, such as Provider Relations and Customer Service, to resolve
claim-related issues and inquiries.
➢ Maintain comprehensive and organized claim records, documentation.

Job Qualifications/Specifications:
➢ Bachelor’s degree in Healthcare Administration, Business, or related field
➢ Prior experience in healthcare claims processing or medical billing, preferably within an HMO or
managed care organization.
➢ Proficiency in medical terminology, CPT, HCPCS, and ICD-10 coding principles.
➢ Familiarity with healthcare reimbursement methodologies, such as DRGs, RBRVS, and fee schedules.
➢ Strong analytical and problem-solving skills with keen attention to detail.
➢ Excellent communication skills, both verbal and written, with the ability to interact professionally
with internal and external stakeholders.
➢ Proficiency in using computerized claims processing systems and software applications.
➢ Ability to prioritize tasks, manage workload efficiently, and meet deadlines in a fast-paced
environment.