Claims Processor

2 weeks ago


Makati City, National Capital Region, Philippines UpRush Social Geekers, Inc. Full time

Job Purpose

This job is responsible for the review, analysis and/or adjudication of claims incurred by eligible members of the Client's Network to ensure that they are according to respective benefits plan, policies and standards

and maintains the records system for these claims.

Duties and Responsibilities
  • Ensures accurate review of claims documents like LOA, hospital bills/SOA, concurrent review form, physician's report, original OR for use in processing claims.
  • Checks on completeness of received claims documents
  • Reviews and matches the endorsed document against the actual encoded data in the system.
  • Reviews/evaluates claims and adjudicates claims to ensure claims are according to benefits plan, coverage and policies and standards.
  • Reviews, evaluates. checks and/or adjudicates claims against ABC, CQS and utilization and existing company policies and procedures for coverage and effectivity of plan
  • Accurately evaluates and processes Outpatient and In-patient claim reimbursement and non-reimbursement, received from various providers and meet the required quota.
  • Responsible for assigning RUV based on surgical procedure done.
  • Responsible for computation of incremental cost and Philhealth.
  • Verifies if the account has adequate funds to cover claim or payment to the provider is released.
  • Coordinates needs and requirements with other concerned departments to facilitate processing and minimize errors
  • Verifies from Hospital doctor in case of dispute regarding claims/checks as the case maybe
  • Generates correct SOAs on medical bills that are non-coverable
  • Reconcile EWB versus payment / accounts, prepare manual SOA
  • Process advance SOA based on suretyship given by Billing Collections.
  • Ensures provision of quality customer service
  • Maintains good relationships with providers by making regular visits and ensuring timely payment of medical bills, in coordination with other departments.
  • Handles inquiries of clients, members and agents regarding application for claims, including handling complaints.
Administrative Responsibilities
  • Undertakes Administrative Responsibilities to ensure proper filing of claims documentation and booking them.
  • Makes accounting entries to book claims transactions
  • Logs and files documents and transmittals of released comments
  • Turns over all processed claims transactions to the Records Room
  • Maintains computerized system used in processing claims thru timely, accurate capturing, recording and dissemination of claims information
  • Prepares Management Reports on claims
Qualifications
  • Graduate of any 4 year course.
  • 1-year experience in Claims processing, adjudication and knowing medical technologies and terms
  • Good grasp of basic claims procedures
  • Knowledge of medical terminologies, comprehension of frequently used medical terms as well as medical conditions and procedures
₱0 - ₱0 a month
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