Claims Processor

URGENT HIRING! This might be your opportunity if you meet the qualifications below:

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.

Work Schedule: Monday to Friday
Working Hours: 8:30 am to 5:30 pm
Work Location: Makati Office