Medical Claims Resolutions Specialist with 25 Night Differential

1 hour ago

Pasig, National Capital Region, Philippines Connext Full time ₱150,000 - ₱250,000 per year

Connext Global Solutions
is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.

We are currently looking for a Medica
Claims Resolution Specialist
who will be working with Connext's Client in the United States of America.

What's in it for you?

  • Competitive compensation
  • Perfect Attendance Bonus
  • Life insurance
  • HMO Insurance
  • Great company culture
  • Annual Merit Increase
  • 25% Night Differential
  • Company provided equipment
  • 10k Sign On Bonus

Job Summary

The Claims Resolution Specialist is responsible for following up on health insurance claims and resolving denied claims through thorough investigation and problem-solving. This role ensures timely reimbursement by addressing root causes of denials and working with insurance companies to secure payments.

Screening Criteria


• High school diploma or an equivalent combination of education and related work experience.


• At least two (2) years of experience in in claims processing or a similar role in the healthcare or insurance industry.


• Must have a stable employment history.

Job Description


• Spends 6-8 hours of day making claims calls.


• Spends hold times basic-statusing claims using provider portals.


• C
onducts claim follow-up/denial resolution every 2 weeks minimum per claim.


• Determines if medical records are necessary and submits requests to the Compliance and Records Department.


• Determines if a Claim Submission Request is required to resolve a claim denial.


• Ensures complete accuracy of information gathered.


• Exhausts all options before requesting an appeal from the assigned onshore agent to be written and mailed in.


• Follows up on and documents appeal statuses.


• Communicates actions that need to be taken to process claims to assigned onshore agent.


•
Documents claim payments issued by check, EFT, or VCC on CollaborateMD and Jira.


• Communicates department needs to assigned onshore agent.


• Maintains up-to-date knowledge of insurance payer requirements.

Required Qualifications


• Strong analytical skills to determine the validity of refund claims and draft appeals effectively.


• Ability to Identify and resolve issues related to refund requests and claim reimbursements in a timely manner.


• Clear and coherent in both written and verbal communication skills to effectively conduct discussions to resolve refund issues and appeals.


• Continuously seeks ways to improve the accuracy and efficiency of refund processing.


• Exhibits sound and accurate judgment in evaluating refund claims and making decisions on whether to approve, deny, or appeal refund requests based on careful consideration of available information.


• Strong time management skills to handle multiple requests and develop realistic action plans to ensure timely and accurate resolution of refund issues.


• Observes safety and security procedures related to handling sensitive payment information to maintain data integrity and confidentiality.

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