Health Claims Officer

Job Qualifications:

• Graduate of any 4-year medical course related.
• Minimum of 5 years in an HMO or health insurance company; and At least 3 years on a Liaison Officer role.
• Working experience/knowledge of health general practice (
• With Pleasing personality and currently residing in any of the following areas: Metro Manila, Metro Cebu & Davao. Okay to travel between locations.
• Excellent interpersonal skills including advanced communication skills, both written and verbal.
• Good presentation skills and ability to speak publicly.
• Good networking skills and confidence in liaising and building strong relationships with stakeholders at all levels internal and external to the organization.
• Ability to prioritize, work to tight and challenging deadlines, and manage complex and multiple pieces of work.

Duties and Responsibilities:

• Assessment / adjudication of “real-time” hospitalization claims of Insured member (i.e currently hospitalized customers
• Analysis of medical documents related to the hospitalization of Insured customer to come up with the correct claims decision.
• Approve amounts (up to P500K) and ensure proper escalations are done for those claim amount beyond their limit.
• Effectively communicating the benefits of the health insurance plan to the customer and to the agents both verbally and in writing
• Ensuring proper case management is conducted to ensure seamless health customer journey for hospitalized customer.
• LOs will engage with hospitalized clients to ensure that the hospitalized members needs are attended to, provide meaningful services during client’s confinement.
• Facilitates administration of health benefits to all members/policy holders through proper coordination between the patient and the provider (Doctors, Hospitals, Clinics);
• Develop, establish, and maintain strong 3rd party relationships with TPA and Providers (Doctors, Hospitals, Clinics);
• Ensure that each third party relationship is implemented and covered by a contract or Memorandum of Agreement (MOA) as applicable.
• Monitors the performance of Company LOs, ensure proper coordination of services of the TPA and Providers and resolve or escalate issues when necessary. Ensure that each Company LO is effectively and efficiently performing within the bounds of their duties and job responsibilities.
• Handles all inquiries, concerns, and requests of member relative to their health benefits.
• Coordinates with the Billing/Collection Department of accredited hospitals regarding the status of confined client-member/s, and with the Liaison office at the Head Office regarding the coverage of the confined client-member/s.
• Gather information or Medical Documents as needed for the assessment of inpatient or hospitalization claims.
• Keeping up-to-date with all factors affecting the service.
• Prepares special reports (daily, weekly, monthly) as required.
• Performs other tasks that may be assigned from time to time.