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.

Job Position: CLAIMS PROCESSOR/ANALYST

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.