Associate BPM Lead

1 week ago

Taguig, National Capital Region, Philippines UST USource Full time ₱900,000 - ₱1,200,000 per year

Responsible for the accurate review/audit of medical claims based defined claims guidelines and policies.

  • Review claims or modifies existing claims according to the appropriate and applicable action
  • Analyze claims to determine appropriate action to approve or deny action done by the agent
  • Determine if accurate payment criteria for clearing pending claims based on defined policies and procedures were applied
  • Research claims edits to determine if appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for entry-level claims was applied by the claims processor
  • Review if provider inquiries regarding claim adjudication were reviewed and addressed
  • Ability to understand and apply knowledge of medical coding (if applicable) and various medical claims forms to the claims process
  • Demonstrate ability to work on high volume of repetitive claims Audit
  • Demonstrate increasing productivity to meet minimum requirements while maintaining quality standards

Education

  • Bachelor's Degree holder preferably in the field of Nursing, Healthcare and Allied Medical Profession an advantage

Work Experience

  • Should have QA experience in Claims
  • Minimum of 2  years experience in medical claims processing experience

Skillset

  • Proficient knowledge on US Healthcare Practice, Medical Coding (ICD-10, CPT4, DRG, HCPCS), Clinical Documentation Improvement, medical terminologies, EDI, and HIPAA protocols is a must
  • Ability to multi-task and follow documented claims processes with minimal supervision
  • Excellent verbal and written business communication skills required
  • Strong proficiency in Windows OS and Microsoft Office applications, particularly Excel
  • Strong attention to detail and the ability to make appropriate decisions based on information presented
  • Good understanding of QA metrics and KPIs

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