Claims Processor

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

Job Qualifications:
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.

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:
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.

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.

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.