Medical Claims Processor Specialist

Job Objective:

Claim Processors are responsible for timely and accurate processing and adjudication of employee benefit claims, related to flexible benefits (FlexBen) and/or health benefit administration (HBA) programs. This role involves reviewing submitted documentation, performing data entry, verifying eligibility, and determining coverage based on plan guidelines. Communicate with issues or exceptions to other concerned departments as necessary.

Job Description:
1. Accurately captures claim data into the claims management system and maintains updated records of all claim transactions, communications, and outcomes.
2. Analyze claims for completeness, accuracy, and compliance with the specific terms of the member’s benefit plan.
3. Confirm the member’s eligibility for benefits and verify that the services or expenses are covered under their current plan
4. Adjudicate and authorize the appropriate payment or refer/escalate claims to concerned parties for further review.
5. Investigate and resolve discrepancies, errors, or issues related to eligible benefits by gathering additional information from the members, other departments, and other stakeholders.
6. Inform employees on the progress of their claims (e.g., pending for review, with missing attachment, or for crediting) based on the agreed ways of working and SLA.
7. Respond to employees’ inquiries or complaints based on the agreed ways of working and SLA.

Background and Qualifications:

1. Candidates must possess at least a Bachelor's/College Degree preferably in health / medical allied courses such as Nursing, Pharmacy, etc.
2. At least 2 year(s) of solid working experience in the related field is required for this position.
3. With experience working in TPA, HMO, insurance or insurance broker companies.
4. Ability to work onsite and extend beyond company operating hours when needed.  

Work Conditions:

1. Onsite work setup

2. Work Schedule: Mondays-Fridays, 8:00AM - 5:00PM

3. Assigned in Greenfield District, Mandaluyong City

4. Occasional travel to build partnerships with institutions and organizations may be expected, as well as attendance at relevant conferences and events