Responsibilities:
- Enter claims data in the claims processing system and review entry for correct adjudication according to patient benefit coverage and provider contracts.
- Responsible for following applicable regulatory and internal policies in claims adjudication.
- Investigate and research claims as necessary to determine or verify members’ eligibility, benefit coverage and required authorizations.
- Deny unauthorized and/or ineligible claims according to client’s guidelines (provider denials vs. member-liability denials).
- Ensure claims payment and denial accuracy within turnaround time.
- Review, evaluate and process all types of claims such as Encounter data, Professional and Institutional Claims for all lines of business e.g., Commercial, Point of Service (POS) Senior/Medicare, Preferred Provider Organization (PPO), Medi-Cal, etc.
- Ensure claims payment & denial accuracy and compliance to turnaround time
Requirements:
- Candidate must possess at least a Bachelor's/College Degree
- With experience in US claims processing
- Ability to analyze data to determine problems and suggest solutions
- Ability to work under pressure and manage a large workload
- Ability to adjust to changes in method, processes and procedures
- Ability to navigate multiple software applications simultaneously
- Ability to work independently and effectively under pressure
- Assertive, self-directed, and resourceful
- Willing to work on graveyard shift, holidays and weekends if required
- with available home internet ( work from home set up)
Job Type: Full-time
Pay: From Php22,000.00 per month
Ability to commute/relocate:
- Makati City: Reliably commute or planning to relocate before starting work (Required)
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