Claims - Junior Manager

Description of the Functions of the Department

The department is responsible for processing the claims and determining whether payment should be made. The department ensures that the following are observed:

• Checks validity/compensability of claims based on the plan coverage/balance and limits up-to-date membership fee payment (active status) completeness of documents submitted charges are based on contracted rates (hospital/clinics) and RUV (doctors)
• Meets the turn-around-time (TAT) in processing valid hospital and doctor claims (provider claims) with complete documents to avail of the incentives (e.g.: prompt payment discounts) being given by the provider and to meet the commitment set in processing and payment of member claims (reimbursement).
• Reviews claims processed if within the coverage (see #1&2)
• Releases reviewed claims to Treasury within the agreed TAT to avail of the discounts and/or meet the commitment with the account/client.
• Reconciles accounts with providers before the set deadline to avoid threats of suspension/suspension.
• Monitors production set if being met by the staff.

DUTIES AND RESPONSIBILITIES OF CLAIMS JUNIOR MANAGER

1. Managerial Responsibilities

• Planning- Prepares the schedule of bills for processing for easy monitoring
• Financial and Resource Management - Reviews current claims processes and make recommendations on which could be automated
• Performance Management - Conducts review of performance of staff Gives feedback to staff re: work performance

2. Technical/Functional Responsibilities

• Bills Receiving- Random checking of documents received.
• Claims Processing - Validates compensability of claim: Check the amount to be paid if within contract rates/RUV; Checks if documents submitted are complete and original copies; Checks amount/claim to be paid if within the coverage/benefit limit and LOA amount Claims Review- Checks the processed claims
• Claims Releasing - Forwards to Treasury reviewed claims for payment
• Claims Reconciliation - Checks/reviews recon of accounts with providers based on the statement of accounts forwarded to us; Check regular recon of accounts with providers or sends confirmation letter to providers on a semi-annual or annual basis
• Claims Report- Submits system-generated reports
• Automation of claims processing and claims processes- Reviews claims processes and initiates/collaborates with ITG for the enhancement or automation of existing processes

3. Business Goals Responsibilities

• Account Retention- Processes provider and member claims within the agreed TAT
• Cost Effectiveness - Monitors staff productivity

4. Administrative Responsibilities

• Submission of Reports- Checks/monitors parameters/filters set for the system-generated reports
• Files- Prepares system based transmittal of documents to record accountability of documents.

QUALIFICATIONS:

1. University degree graduate in related field

1. At least 2 years of related work experience from an HMO or insurance industry

2. Competencies:

3. Oral Communication – effectively expresses self in individual or group situations (includes gestures and nonverbal communication

4. Written Communication – clearly and briefly expresses ideas in writing and in correct grammatical form
5. Attention to Detail – totally accomplishes task through concern for all areas involved, no matter how small
6. Flexibility – shows openness to different and new ways of doing things, modifies preferred way of doing things when appropriate
7. Integrity – maintains social, ethical and organizational norms in job-related activities, trustworthy, walks his talk
8. Fostering Teamwork – as a team member, has the ability and desire to work cooperatively with others in the team; as a team member, demonstrate interest, skill and success in getting groups to work together towards a common goal
9. Results-Orientation – focuses on the desired results of the unit's work, focusing effort on the goals and meeting or exceeding them, sets appropriate work standards and establishes monitoring system
10. Analytical – relates and compares data from different sources, identifies issues, secures relevant information and identifies relationship
11. Organizational Sensitivity – perceives the impact and implications on other components of the organization
12. Technical Savvy – is able to use computer system and basic computer softwares relevant to their job assignment

13. Demonstrated ability to establish trust and manage through difficult circumstances while maintaining respect, dignity and integrity.

14. Must be willing to work in:

15. Office-based set-up

16. With occasional visits to providers
17. Can work beyond 8hrs