Claims Processor

Job Qualifications:
A. Educational Background:
-Bachelor’s degree in Business administration, Healthcare Management, Nursing, or a
related field is preferred.
-A diploma in medical, healthcare, or business-related field may be considered.
Experience:
-1-2 years of relevant experience in medical claims processing or administrative support
in healthcare, hospitals, clinics, or insurance/HMO industries.
-Familiarity with medical billing and reimbursement processes.
-Experience working with HMO procedures and healthcare provider networks is a plus.

B. Skills:
-Attention to Details: Accurate and thorough in reviewing medical claims, documents,
and codes.
-Analytical Thinking: Ability to interpret policy coverage, medical reports, and supporting
documents to identify discrepancies or irregularities.
-Communication: Strong written and verbal communication skills to coordinate with
hospitals, clinics, and policyholders.
-Technical Proficiency: Proficient in medical claims processing systems, Microsoft Excel,
MS Word, and email platforms.

-Problem-solving: Capable of investigating claims issues and resolving them in a timely
and efficient manner.

Other Qualifications:
-Familiarity with ICD, CPT, and HCPCS codes and medical terminology.
-Knowledge of insurance guidelines, HMO processes, and regulatory compliance.
-Ability to multitask and work efficiently under time constraints.
-Excellent organizational and documentation skills.

Job Specifications:
A. Claims Processing:
-Review and process medical claims submitted by members or healthcare providers.
-Check documents for completeness, including medical abstracts, itemized statements,
and official receipts.
-Verify member eligibility, benefits coverage, and policy limits.
-Apply appropriate coding and benefits computation based on the member’s plan and
HMO rules.
B. Data Entry & Record Keeping:
-Encode claims data into the medical claims processing system.
-Maintain updated records of approved, denied, and pending claims.
-Document any adjustments, follow-ups, and discrepancies.
C. Claims Evaluation:
-Evaluate claims against policy provisions and clinical guidelines.
-Detect potential fraud, abuse, or claim duplication.
-Coordinate with medical providers to validate unclear or questionable claims.
-Accurately calculate payable amounts, co-pays, and exclusions.

Monthly Salary: PHP 18,000
Work Schedule: Monday to Friday
Working Hours: 8:30 am to 5:30 pm
Work Location: Makati Office