JOB PURPOSE:

Responsible for analyzing, adjudicating, auditing and processing of claims (Member’s Reimbursement) according to set medical guidelines, policies within the agreed SLAs (Service Level of Agreements).

Principal Accountability: 

1. Ensures accurate and timely processing of claims from medical service providers within authority limits. This involves 

   • Accurate claims adjudication as per medical guidelines and policies 

   • Accurate claims adjudication as per agreed business Standard Operations Procedures within agreed SLAs 

   • Escalation of claims as per agreed SOP 

2. Review and escalation of medical codes, supporting documents and observations to determine medical appropriations Researches and determines medical related claims 

3. Maintain records, files and documentation as appropriate 

4. Processes claims within the set TAT (Turned-Around Time) 

5. Approves claims up to Php 4,000.00 

6. Meet daily target/quota requirements. 

7. Meets 100% productivity / efficiency.  

8. Monitors and handles all inquiries from members (Status of claims) 

9. Correct adjudication/entry of audited claims to address audit findings. 

10. Prepares Denial/Disapproval letters to the Members for the non-coverable charges.  

11. Inform members/clients with incomplete documents submitted.  

12. Prepares memo to IST for any changes or correction of payee name.  

13. Assists in telephone inquiries of members/brokers and agents. 

14. Recommends strategies towards improvements of the department  

15. Performs other duties assigned by the immediate superior from time to time. 

Activity based: 

1. Processing of Members’ Claims that includes: 

   • Verification of Member’s Name, Membership Status, Identification Number, accommodation, Plan Type & Payee. 

   • Checking for the accreditation status of the physician and facility. 

   • Checking of Statement of Account, the completeness and accuracy of submitted documents. 

   • Coordination with Hospital Liaison Officers/and or Medical Services Center (MSC) and/or review of the Health Care Agreement regarding other special endorsements relative to the particular availment/confinement 

   • Assignment of ICD – 10 codes for corresponding diagnosis of each member 

   • Segregates expenses/charges per illness according to services rendered  

   • Assignment of RVS &/or hospital visitation/consultation rates for doctors 

   • Checking of PhilHealth (PHIC) portion 

   • Initial assessment whether the processing may proceed 

   • Encoding of Information in the Medical claims Database (Oracle & MAS) 

2. Audit of all processed claims within the approval level 

3. Assist follow-up of payments and inquiries 

4. Assist in telephone inquiries of Accredited providers and Members. 

5. Recommends strategies geared towards improving the operations of the section. 

6. Performs other duties from time to time that may be assigned by the immediate superior. 

In support of Company operations, the incumbent may be assigned to perform related functions from time to time.  

INTERACTION: 

Inside (company personnel): 

• AMG/Sales Staff 

• Accounting Staff 

• IST Staff 

• HLO Staff 

• MSC Staff 

• PAR Staff 

Outside (with non-company personnel): 

• Hospitals & Other facilities Staff  

• Doctors 

• Secretaries of doctors

Qualifications:

1. Graduate of any medical course  

2. Experience in processing medical claims reimbursement

   Experience in Accounts Payable (AP) or Accounts Receivable (AR) is also welcome

3. Skills knowledge

   • Strong analytical skills 

   • Highly developed verbal and written communication skills 

   • Ability to analyze and interpret complex documents. 

   • With high attention to details 

   • Proficient in computer skills 

   • Excellent organization and interpersonal skills 

   • Strong customer service skills and high level of professionalism

4. Willing to work onsite in Makati

Please refer to job description.