Claims Configuration Specialist

3 hours ago

Taguig, National Capital Region, Philippines Private Advertiser Full time ₱800,000 - ₱1,200,000 per year

We currently looking for Registered Nurse to be part of our team

The Claims Configuration Specialist is responsible for configuring  all aspects of health plan benefit, fee schedule setup, managing our pre-pay edits, analysis, mapping, testing, troubleshooting, and implementation.

The ideal candidate will act as a liaison across all departments regarding benefit and provider contract interpretation issues, ensuring seamless operations and effective communication.

Responsibilities :
  • Manage all aspects (interpretation, analysis, implementation and audit) of claims configuration including but not limited to benefits, contracts, Devoted denial library
  • Coordinate edits across the different partners to ensure there are no conflicts and they work with in conjunction with each other
  • Ensure edits are defensible and appropriate
  • Preparing, completing, and monitoring benefit and fee schedule configuration for annual 1/1 readiness
  • Ensure monthly and quarterly pre-pay edit data is loaded and ready for use
  • Assist with monthly audits of all vendor denial edits and maintain highest level of quality with the inhouse denial reason library
  • Review, validate and maintain all new, updated, and deleted medical codes published by CMS/AMA/WHO in all relevant tables.  Communicate changes to appropriate stakeholders
Qualification :
  • Must be registered Nurse with Active License
  • Must have experience in Claims configuration or Denials management
  • Must be familiar with CCI/Pre pay and CMS Guidelines
  • In-depth knowledge of health insurance claims processing, regulations, and compliance requirements. Ability to research and understand Medicare regulations
  • Detailed-oriented with strong analytical and problem-solving skills, with proficiency in data analytics tools
  • Strong written, verbal, and interpersonal communication skills

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