Claims Specialist

1 week ago


Makati, Philippines Dempsey Resource Management Inc. Full time

Responsibilities 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 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; Analytical thinking; Communication; Technical proficiency; Problem-solving. Proficiency in medical claims processing systems, Microsoft Excel, MS Word, and email platforms. 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. #J-18808-Ljbffr



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