Head of Claims Administration

2 weeks ago

Manila, National Capital Region, Philippines Simpletpa Full time
  • As the Head of Claims and Customer Service (CS) for Discover ASO Corp. aka SIMPLeTPA, he/she is primarily responsible to assure claims are managed within the specific plan guidelines and charges for claims services are reasonable and customary. In order to perform this role in an efficient manner, the Head of Claims and Customer services will be integral involved as the subject matter expert (SME) for the design and development of our digital claims adjudication and management platform. To support this role, Head of Claims and CS will directly manage the company's customer service relationship team, escalate concerns and deploy preventive measures to address possible issues of clients that may arise. As a founding team member, he/she will have the opportunity to heavily influence the overall company, market and platform development.As the scale of the operation increases, there will be an opportunity to level up the Claims and CS roles to fit the scale.

SERVICES TO MARKET

  • Claims Adjudication, Customer Service, Relationship Management, Business Management, Customer Experience

DUTIES AND RESPONSIBILITIES

  • Support the design, implementation and continuous management of the rapid claims management system – including gathering and monitoring claims costs on a treatment and/or DRG basis. The role involves keeping up on trends and innovation in the healthcare industry that is delivering better healthcare outcomes at the best price.
  • Work with insurance and healthcare partners to assure proper alignment and coordination on all claims processing where applicable
  • Direct and manage team of claims adjudicators and customer services specialist to adjudicate non-standard claims; where necessary monitors daily patient's progress chart to know patient's needs.
  • Monitor and audit claim trends for potential fraud or overutilization; explore alternate and preventative medical treatments/protocols
  • Work as key team member for building out the claims management platform to deliver customer-centric solutions to ease the healthcare process and mitigate any surprises in the claims/GOP processes
  • Address and act as key decision maker with customers, medical providers or other interested parties when dealing with special or challenging medical conditions and/or treatment decisions
  • Continuously update and maintain databases required to support the claims adjudication system (includes both list of preferred providers as well as the industry standard "usual and customary" costs and protocols for specific conditions
  • Draft and maintain appropriate risk management guidelines and policies for medical decision making, appeal processes and other related issues for both SIMPLeTPA self-insured plans as well as plans provided in coordination with other insurance companies
  • Manages the workload balance, including acting as a backup as required
  • Develops tools and reports for claims and customer service performance as needed

QUALIFICATIONS

  • With 8+ years of relevant experience in medical claims processing
  • Demonstrated experience working with medical providers to resolve difficult claim cases
  • History of innovative, creative and driven worker
  • Prefer graduate of medical, nursing or related medical certification programs
  • Excellent written and verbal communication skills
  • Knowledgeable on digital enterprise workspace productivity tools (e.g. excel, word and ppt or equivalent); experience working with data analytic tools highly appreciated

ACKNOWLEDGEMENT AND ACCEPTANCE

I certify that I have read and I understand the duties and responsibilities and other features and dimensions of the job, as specified and stated in this Job Description. I accept these duties and responsibilities and agree to maximize and optimize existing competencies and develop new competencies to achieve the different performance and competency standards.

#J-18808-Ljbffr

  • Claims Head

    2 weeks ago

    Manila, National Capital Region, Philippines Sun Life Full time

    Claims Head Sun Life Financial, Inc. Manila, Philippines Posted 7 days ago Permanent Competitive Claims Head You are as unique as your background, experience and point of view. Here, you'll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge...

  • Claims Team Head

    2 weeks ago

    Manila, National Capital Region, Philippines BDO Unibank Full time

    He/She/They will be responsible for overseeing the claims processing, and operational activities of assigned section. Ensures efficient claims processing of assigned accounts through equitable settlement of claims filed at the soonest possible time based on insurance policy coverage and conditions. Assists the Team Head and/or Unit Head in developing...

  • Claims Manager

    2 weeks ago

    Manila, National Capital Region, Philippines Medicare Plus Full time

    We are currently seeking a highly experienced and motivated Claims Manager to join our insurance team in the Philippines. As a Claims Manager, you will be responsible for overseeing the processing and settlement of insurance claims, ensuring that all claims are handled accurately, efficiently, and in accordance with company policies and regulations.Key...

  • Micro HMO Claims Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines Pioneer Your Insurance Full time

    YOUR ROLE:Contributes to the management of the department's loss ratio by evaluating simple claims cases and handling detected suspicious or fraudulent cases according to the established claims standards and guidelines of the department and Pioneer Group to ensure that claims settlements are fair for both our customers and Pioneer at all times. Contributes...

  • Micro HMO Claims Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines Pioneer Your Insurance Full time

    YOUR ROLE:Contributes to the management of the department's loss ratio by evaluating simple claims cases and handling detected suspicious or fraudulent cases according to the established claims standards and guidelines of the department and Pioneer Group to ensure that claims settlements are fair for both our customers and Pioneer at all times. Contributes...

  • Coordinator

    2 weeks ago

    Manila, National Capital Region, Philippines VA Claims Insider Full time

    TheELITE Program Coordinator I (EPC)supports the Veteran Coach Manager (VCM), Veteran Coach (VC), and Lead ELITE Program Coordinator (LEPC). The ELITE Program Coordinator I will perform various administrative support duties for an individual, group, or department to ensure team operations run smoothly and efficiently.This will include: managing and...

  • Contracts Administrator

    2 weeks ago

    Manila, National Capital Region, Philippines Shimizu Philippine Contractors, Inc. Full time

    Qualifications:Graduate of Civil EngineeringWith at least 5 years of experience in Contracts administration in construction companyWith knowledge in FIDIC Duties and Responsibilities: Provide support in the tender stage such as preparation of different documents and drafting of proposal conditionsProvides support during awarding stage such as drafting and...

  • Contracts Administrator

    2 weeks ago

    Manila, National Capital Region, Philippines Shimizu Philippine Contractors, Inc. Full time

    Qualifications:Graduate of Civil EngineeringWith at least 5 years of experience in Contracts administration in construction companyWith knowledge in FIDIC Duties and Responsibilities: Provide support in the tender stage such as preparation of different documents and drafting of proposal conditionsProvides support during awarding stage such as drafting and...

  • Head Nurse

    2 weeks ago

    Manila, National Capital Region, Philippines Our Lady of Lourdes Hospital Full time

    PRINCIPAL RESPONSIBILITY:The Head Nurse plans, organizes, and leads the activities within the assigned unit for optimum patient care. He / She is directly responsible for the physical set-up of the unit, structure and other human resources for health care provision. He / She collaborate with other members of the healthcare team in meeting the needs of the...

  • Admin Head

    2 weeks ago

    Manila, National Capital Region, Philippines Telan Solutions Telan Hipe Flores Telan & Associates Full time

    Telan Solutions / Telan Hipe Flores Telan & Associates Office Management (Administration & Office Support) · Supervising the day-to-day operations of the administrative department, staff members, building maintenance personnel and utility men.· Developing, reviewing, and improving administrative systems, policies, and procedures.· Ensuring the office is...

  • Administrative Assistant

    2 weeks ago

    Manila, National Capital Region, Philippines SVT Meditech Corporation Full time

    Administrative AssistantResponsible in providing support in service orders, warranty claims, case monitoring and closure, and other engineering support activities. Minimum Qualifications:• Candidate must possess at least a bachelor's degree in Business Administration Management, Logistic Management or equivalent.• With at least one (1) years operations...

  • Administrative Assistant

    2 weeks ago

    Manila, National Capital Region, Philippines SVT Meditech Corporation Full time

    Administrative AssistantResponsible in providing support in service orders, warranty claims, case monitoring and closure, and other engineering support activities. Minimum Qualifications:• Candidate must possess at least a bachelor's degree in Business Administration Management, Logistic Management or equivalent.• With at least one (1) years operations...

  • Associate 2

    2 weeks ago

    Manila, National Capital Region, Philippines Sun Life Financial Full time

    locations Taguig City, National Capital Region (Manila) time type Full time posted on Posted Yesterday job requisition id JR You are as unique as your background, experience and point of view. Here, you'll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share...

  • Human Resource Administrator

    2 days ago

    Manila, National Capital Region, Philippines Asian Development Bank Full time

    Job DescriptionDescription –>The Human Resource Administrator (HR Services) will provide technical and operational support in BPRS to ensure the quality of HR benefits and services for ADB staff that include benefits administration and other HR related operations. The incumbent will report to the designated International and National...

  • Contracts Administration Senior Associate

    1 week ago

    Manila, National Capital Region, Philippines NLEX Corporation Full time

    Qualifications & experienceGraduate of any four (4) year course, preferably Civil Engineer or equivalent.Tasks & responsibilitiesEnsure complete administration of contracts related to operations and support and monitor compliance of service providers with contract terms.Review agreed terms and conditions and attend pre- implementation sessions with process...

  • Kitchen Head

    2 weeks ago

    Manila, National Capital Region, Philippines CloudEats Full time

    About the job Kitchen Head - Metro ManilaWe are looking for experienced and creative Kitchen Heads to lead our kitchens in the following locations:The Kitchen Head will be responsible for overseeing daily kitchen operations, managing staff, and ensuring that all dishes meet our high-quality standards. The ideal candidate should possess strong leadership...

  • Branch Head

    2 weeks ago

    Manila, National Capital Region, Philippines Bank of Commerce (Philippines) Full time

    DUTIES AND RESPONSIBILITIES:1. FINANCIALa. Ensures attainment of deposit and profitability targets thru delivery of budgeted business volumes and efficient cost management.b. Spearheads the cross-selling of the Bank's corollary products and services, such as but not limited to commercial and consumer loans, credit cards, etc.c. Refers customers with fixed...

  • Head Nurse

    2 weeks ago

    Manila, National Capital Region, Philippines Our Lady of Lourdes Hospital Full time

    The Head Nurse plans, organizes, and leads the activities within the assigned unit for optimum patient care. He / She is directly responsible for the physical set-up of the unit, structure and other human resources for health care provision. He / She collaborate with other members of the healthcare team in meeting the needs of the patients. The Head Nurse...

  • Administrative Assistant

    3 days ago

    Manila, National Capital Region, Philippines AIA Philippines Full time

    Job Description SummaryResponsible for providing administrative support to the Territory Sales Head (TSH) and his/her Bancassurance Division Managers (BDMs) Roles and Responsibilities: Generate daily, weekly and monthly reports as required by the TSH and the BDMsMaintain files, records, calendars and diariesAssist the TSH and BDMs in the...

  • Administrative Assistant

    1 week ago

    Manila, National Capital Region, Philippines Hexagon Group of Companies Full time

    MAIN PURPOSE OF THE JOBProvide necessary operations assistance to the Operations Manager - Property and/or Building Manager and to the tenants.Monitor concerns, complaints and requests from tenants and assist in liaising with tenants to ensure their continued satisfaction.Facilitates the processing of accounts payable, releasing of the Statement of Accounts...