Benefits Assistant

Duties and Responsibilities

I. Eligibility Verification

Focuses on verifying patient eligibility by patient interview, and ensuring all initial forms are completed.

• Conducts PhilHealth Eligibility Verification using the official PhilHealth portal for all new admissions.
• Answers and provide advice to patient's inquiries regarding PhilHealth coverage and eligibility concerns.
• Occasionally perform patient-room visits to provide assistance and information for patients without companions.
• Initiates Claims Documentation by providing the Claim Signature Form (CSF) and a blank Claim Form 4 (CF4) to be attached to the patient's medical chart upon admission.

II. Benefits Registration and Pre-Authorization Management

This covers the specialized pre-registration and authorization required for specific procedures.

• Manages registration to PhilHealth Dialysis Database (PDD) for all new Hemodialysis patients.
• Secures Cataract Pre-Surgery Authorization (CPSA) for all patients scheduled for cataract operations.

III. Claims Processing and Coding

This is the core claims analysis, coding, and computation phase, requiring strong attention to detail and knowledge of PhilHealth policies.

• Performs claims analysis by reviewing the patient's diagnosis, procedures, and length of stay to determine the appropriate case rate benefits in conformity with current PhilHealth circulars.
• Assigns clinical codes, including the appropriate ICD-10 code for each diagnosis and RVS code for surgical procedures when not initially available on the chart.
• Conducts chart inquiries if needed across various departments (Nurses' Station, OR, ER, Hemodialysis, Molecular Lab) to gather complete clinical data.
• Collaborates with Attending Physicians if needed to clarify and confirm final diagnosis and procedure codes.
• Determines Case Rate amount using the PhilHealth Case Rate Search (CRS) to compute the correct benefit amount.
• Calculates and forward case rate computation to the Billing Department, including the correct PhilHealth computation for both the Hospital Bill and Professional Fees, for system encoding.
• Processes PhilHealth benefits via PhilHealth Information System (PIS), ensuring all required information is accurately entered.
• Prepares and explains PhilHealth forms for member/relative signing, clearly detailing the corresponding PhilHealth benefits.
• Forwards soft copy of clinical chart, including patient history and diagnostics, to the head for final review and approval.

IV. Claims Finalization and Electronic Transmittals

This focuses on the final assembly and electronic submission of the claims document.

• Maintains claim completeness by attaching a checklist form and verifying all appropriate boxes are checked for a complete claim submission.
• Logs Hemodialysis sessions by accurately tracking and recording daily sessions into each patient's calendar.
• Prepares CF4 Forms for Hemodialysis patients by encoding patient data into the system and printing the final form.
• Coordinates Final Discharge by requesting the patient account discharge and the daily discharged list from the Billing Department.
• Secures Physician signatures on the Claim Signature Form (CSF) from the Attending Physicians via their medical secretaries.
• Transfers complete claims to the transmittal area after securing all required signatures and mandatory documents.
• Finalizes transmittal process by receiving claims from the processing area, verifying their completeness, and electronically transmitting the claims through the PhilHealth Information System (PIS).
• Ensures 100% Claims Transmittal and monitors unsubmitted claims.

V. Claims Resubmission, Compliance, and Monitoring

This outlines the process for handling returned-to-hospital (RTH) claims and ensuring prompt re-filing and payment monitoring.

• Receives and analyzes RTH Claims
• Accepts the returned-to-hospital (RTH) notification letter from the Claims Head and thoroughly analyzes the reasons for the claim denial or deficiency.
• Ensures Compliance
• Executes all necessary corrective actions and secure all required compliance documents based on the specific requirements detailed in the RTH letter.
• Facilitates Department head review
• Compiles and forwards the completed compliance requirements to the Head for final review and verification.
• Processes Electronic Resubmission
• Electronically process the refiling of the corrected claim through the PhilHealth Information System (PIS) in a timely manner.
• Maintains and monitors RTH Log
• Accurately log the refiling history for each RTH claim and actively monitor its payment status.

VI. External Liaison and Documents Submission

This covers the responsibility for coordinating and submitting physical documentation to PhilHealth offices.

• Prepares and verifies submissions:
• Receives and verifies the completeness of all physical documents compiled for manual submission to PhilHealth.
• Facilitates Document Delivery:
• Act as the designated liaison to coordinates and executes the manual submission of claims-related or legal documents to the respective PhilHealth Local Health Insurance Office (LHIO) and/or the PhilHealth Main Office.
• Ensures Document Control:
• Secures an official received copy or transmittal log for all submitted documents to ensure proof of delivery.

VII. Performs other duties and responsibilities as assigned by the Head.

Qualifications

Education: Graduate of any medical-related course (e.g., Nursing, Medical Technology, Pharmacy, etc.)

Experience: Prior experience in PhilHealth claims processing or hospital benefits administration preferred.

Technical Skills:

• Familiarity with PhilHealth Information System (PIS) and BizBox software
• Knowledge in ICD-10 coding (an advantage)
• Proficient in MS Office (Excel, Word, Outlook)

Soft Skills:

• Excellent attention to detail and analytical skills
• Strong communication and coordination abilities
• Ability to work under pressure and meet deadlines

Job Types: Full-time, Permanent

Benefits:

• Employee discount
• Free parking

Education:

• Bachelor's (Required)

Work Location: In person