Hospital Claims Specialist

Job Description:

Hospital Claims Specialist - Potential WFH after Training

Location: Makati
Employment Type: Full-time
Work Setup: Onsite for the first 6 months, with potential work-from-home eligibility thereafter based on performance and business needs

THIS IS AN URGENT HIRING We will prioritize those who can commit and start ASAP.

About the Role

We are looking for a highly experienced Hospital Claims Specialist with strong hands-on expertise in US healthcare facility claims adjudication. This role is ideal for a candidate who has worked in a payer, TPA, or managed care environment and can independently review, analyze, and resolve complex hospital claims with accuracy, consistency, and sound judgment.

The ideal candidate has deep knowledge of institutional billing, hospital reimbursement methodologies, and policy-based claim decision-making, and is confident handling complex inpatient and outpatient claims while meeting productivity, quality, and compliance standards.

Key Responsibilities:

Hospital Claims Adjudication

• Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, ancillary, Home Health, and SNF claims, in accordance with benefit plans, policies, and standard procedures.
• Validate claim accuracy and completeness, including:
  • member eligibility and cost share
  • provider affiliation and reimbursement
  • code validity
  • dates of service
  • authorization and referral requirements
  • supporting documentation
• Make accurate claim determinations to pay, deny, adjust, pend, or contest claims, supported by proper rationale and documentation.
• Apply member cost share correctly, including deductibles, copayments, coinsurance, benefit limits, and coordination of benefits (COB).
• Identify payment integrity issues such as duplicate billing, coding discrepancies, billing errors, and policy inconsistencies.

Investigation & Complex Claim Resolution

• Research and resolve

  pended, high-dollar, high-risk, or complex hospital claims through analysis of system data, claim history, itemized bills, clinical records, and authorization details.

• Exercise sound judgment in reviewing claims that require deeper investigation and independent decision-making.
• Identify unclear policy interpretation, configuration gaps, and system-related issues, then elevate with clear findings and recommendations.

Documentation, Compliance & Quality

• Maintain clear, complete, and audit-ready claim notes to support all claim decisions.
• Ensure adherence to HIPAA, PHI privacy standards, internal controls, and regulatory requirements.
• Participate in quality reviews, calibrations, and continuous improvement initiatives to reduce errors and improve accuracy.
• Support internal and external audits by providing documentation and explanation of claim decisions when needed.

Required Qualifications

• At least 5 years of hands-on experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting.
• Strong working knowledge of institutional billing, including UB-04 and 837I claim formats.
• Proven experience handling inpatient, outpatient, emergency room, Home Health, and SNF claims, including complex cases.
• Solid understanding of:
  • DRG / APR-DRG reimbursement methodologies
  • Medicare and Medi-Cal claims processing
  • prior authorization and referral requirements
  • eligibility and benefits
  • timely filing rules
  • coordination of benefits
  • overpayment and underpayment identification
• Ability to independently interpret:
  • provider contracts and reimbursement terms
  • payer policies
  • benefit summaries
  • claims processing guidelines
• Strong analytical skills, attention to detail, and sound judgment.
• Experience handling complex denials, pricing logic, payment integrity review, and high-dollar institutional claims is highly preferred.
• Familiarity with payer platforms and claims adjudication systems.
• Clear and confident English communication skills, including the ability to write concise and defensible claim notes.

Preferred Qualifications

• Experience supporting Commercial, Medicare Advantage, or Medicaid plans.
• Familiarity with appeals, reconsiderations, or provider dispute resolution.
• Working know