Senior Medical Claims Specialist

1 week ago

Davao City, Davao, Philippines Connext Global Solutions Inc Full time ₱900,000 - ₱1,200,000 per year

Connext Global Solutions is a team of business process outsourcing experts and innovators, trusted by world-class companies across industries such as Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.

We are currently looking for a Senior Medical Claims Resolution Specialist to join our growing team and support one of our U.S.-based healthcare clients.

Why Join Connext?
  • Competitive Compensation
  • Perfect Attendance Bonus
  • Life Insurance & HMO Coverage
  • 25% Night Differential
  • Annual Merit Increase
  • Company-Provided Equipment
  • Great Company Culture that values growth and collaboration
Job Summary

The Senior Medical Claims Resolution Specialist plays a critical role in ensuring accurate and timely processing of medical claims. This position supports the Claims Payable team in claim ingestion, discrepancy investigation, stakeholder collaboration, and overall claims management to drive efficiency and accuracy.

Job Description
  • Review and process value-based care claims for accuracy, compliance, and reimbursement alignment.
  • Investigate discrepancies and collaborate with internal and external partners to resolve issues.
  • Ensure timely and accurate claim payments, applying reimbursement rates and adjustments.
  • Maintain complete documentation of claims activities, payments, and provider communications.
  • Collaborate with Provider Relations, Contracting, and Finance teams to address claim-related concerns.
  • Manage EDI enrollments with ACO payer IDs through TPA vendors and assist provider groups.
  • Oversee QuickCap registrations, password resets, and virtual groupings.
  • Audit ACH information to ensure accuracy in claims payment delivery.
  • Facilitate provider education sessions prior to each Program Year (Vytal Step requirements).
  • Support process improvements and initiatives to enhance claims workflows and provider experience.
  • Stay updated on industry regulations, reimbursement trends, and best practices.
  • Participate in training and development to strengthen expertise in claims processing and value-based care.
  • Assist with ad-hoc projects assigned by leadership.
Qualifications
  • Strong knowledge of U.S. medical claims processing, including Medicare and Medicaid.
  • Expertise in medical claims payment posting, AR review, and CARC (Claim Adjustment Reason Code) interpretation.
  • Experience with EDI enrollment processes, payer setup, and system configuration.
  • Ability to build queries and generate reports for claims data analysis.
  • Proficiency in medical billing software and industry platforms.
  • Skilled in Microsoft Office (Word, Excel, Outlook).
  • Strong problem-solving skills with keen attention to detail.
  • Excellent written and verbal communication skills in English.
  • Collaborative team player with a focus on accuracy, efficiency, and provider satisfaction.

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