Healthcare Claims Adjudication Lead

Healthcare Claims Adjudication Lead

Work Set-Up: In-Office Training Required | Potential for Remote Work After Training

Location: Makati, Valero

Expected Start Date: December 8, 2025

Position Summary:

We are seeking a dynamic and experienced Healthcare Claims Adjudication Lead to oversee our growing healthcare team. This role is pivotal in ensuring timely, accurate, and compliant processing of health insurance claims and payments. You will lead a high-performing team, drive operational excellence, and foster a positive work environment that inspires collaboration and growth.

If you are passionate about operational excellence, team development, and driving measurable results, this is your opportunity to make a real impact.

Key Responsibilities:

Team Leadership & Development

• Manage daily operations of the claims adjudication team, including workload distribution and task prioritization.
• Motivate and coach team members to achieve accuracy and productivity targets.
• Conduct regular training sessions to enhance product knowledge, compliance awareness, and technical skills.
• Empower team members through mentoring and constructive feedback during quarterly performance reviews.
• Foster a positive and collaborative work environment that encourages continuous improvement.

Operational Excellence

• Oversee end-to-end claims adjudication processes, ensuring compliance with payer requirements and industry standards (HIPAA, CMS).
• Review and resolve complex or escalated claims issues, providing guidance and support to team members.
• Analyze adjudication trends and identify opportunities for process optimization.
• Ensure adherence to service-level agreements (SLAs) and organizational KPIs.

Quality Assurance & Compliance

• Implement quality control measures to maintain high accuracy in claims adjudication.
• Conduct audits and apply corrective actions to ensure compliance with regulatory guidelines.
• Stay updated on changes in healthcare regulations and communicate updates to the team.

KPIs & Success Metrics:

• Claims Accuracy Rate: Maintain 98%+ accuracy in adjudicated claims.
• Turnaround Time: Ensure claims are processed within SLA timelines.
• Team Productivity: Achieve monthly targets for claims processed per team member.
• Compliance Score: Maintain 100% adherence to HIPAA and CMS guidelines.

 Qualifications & Skills:

• Experience: Minimum 3-5 years in a Supervisory level in healthcare claims processing, denials and appeals, or end-to-end claims adjudication is REQUIRED.
• Strong leadership and people management skills with a proven ability to motivate and develop teams.
• In-depth knowledge of healthcare claim types, payer requirements, and industry standards (HIPAA, CMS).
• Hands-on experience with claims management software and electronic submission platforms.
• Excellent written and verbal communication skills.
• Strong analytical, problem-solving, and critical thinking abilities.
• Ability to work independently and collaboratively in a fast-paced environment.

Requirements & Work Arrangement: 

• Amenable to work graveyard hours/night shift
• Can start ASAP. This is an urgent hiring.
  
• Work Arrangement: This position is currently offered on a remote work basis after successful completion of training (In-office). However, please note that this is a performance-based role, and the company reserves the right to require employees to report onsite at any time based on business needs, performance evaluations, operational requirements. Flexibility to transition to an office-based setup when necessary is expected.
  
  

Additional Benefits:

• HMO - Medical & Dental (coverage on Day 1 plus 1 dependent)
• Transportation Allowance
  
• Equipment will be provided
  

COMPANY OVERVIEW:

Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans' members and providers. 

The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans' members and providers.  The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually.  The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance and automation of claims operations for its clients.

Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.