Provider Dispute Claims Processor

Job Title: Provider Dispute Claims Processor | In-Office Training Required | Potential for Remote Work After Training

Expected Start Date: September 22

Salary: up to Php 35,000

Position Summary:

We are seeking an experienced Provider Dispute Claims Processor this role is responsible for reviewing, researching, and resolving provider disputes in compliance with regulatory guidelines and internal policies.

The ideal candidate will have hands-on experience and knowledge of Medi-Cal and Commercial Insurance Claims.

This position plays a critical role in maintaining provider satisfaction and ensuring compliance with dispute resolution timelines.

Key Duties:

• Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed claims
• Utilize EZCap to review claims history, adjudication data, and notes
• Interpret health plan policies, provider contracts, and regulatory requirements (especially Medi-Cal and commercial plans)
• Reviewed healthcare claims for accuracy and compliance, ensuring timely resolution across multiple specialties.
• Evaluated authorization details and validated codes to ensure claim approval and compliance.
• Detected discrepancies that led to appropriate claim denials or adjustments, reducing erroneous payments.
• Collaborated with internal quality auditors, resulting in a 15% improvement in claims accuracy within the first year.
• Process and review healthcare claims across multiple specialties (Anesthesia, ARI, DME, Facility, MSK, Surgery, PAP Supplies, COB, and Lab).
• Verify eligibility, coverage, CPT codes, and supporting documentation for both Primary and Secondary Medicare claims.
• Identify discrepancies and determine whether to approve, deny, or adjust claims per policy guidelines and medical necessity.
• Maintain 98%+ accuracy in claims adjudication while consistently meeting turnaround time (TAT) and quality assurance standards.

Required Qualifications:

• High school diploma or equivalent; associate or bachelor's degree is a plus.
• At  least 3–5 years of hands-on experience in provider dispute resolution within healthcare, third-party administrator (TPA), or health plan settings, including claims processing and adjudication.
• Proficient in CPT, ICD-10, and HCPCS coding validation; experienced in handling Medicare claims and secondary coverage.
• Skilled in claims denials, adjustments, and appeals processes; strong knowledge of authorization and eligibility verification.
• Familiar with HIPAA, data privacy regulations, and basic cybersecurity standards.
• Strong background in data analysis and visualization to identify trends, improve workflows, and support decision-making.
• Claims Adjudication Systems: Experienced with platforms such as IDX and Facets.
• Tools: Proficient in Microsoft Office Suite (Excel, Outlook, Word), with advanced Excel skills.
• Can start ASAP.

Requirements & Work Arrangement:

• Working Hours: Night shift; must be flexible to work holidays and weekends if required.

• Internet Requirements: A minimum of 25 Mbps download / 5 Mbps upload is required and must be hardwired.

• Work Environment: A quiet, dedicated workspace is required.

• 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 Day1 plus 1 dependent)
• Transportation Allowance
• Internet 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.