Job Specifications:

1. Open to hybrid work arrangement.
2. Graduate of a Bachelor’s Degree of any allied medical profession.
3. License is preferred – RN, PTRP, RPH or OD.
4. 3+ years medical, healthcare or clinical experience in an inpatient hospital setting is required.
5. Minimum of one year Philippine or US healthcare insurance and claims experience is required,
6. Knowledge of healthcare insurance and medical terminology; Codes–ICD-9, CPT, HCPCS; CMS/ADA Claims Forms; Medicare and NCCI guidelines’ Fee Schedules and HIPAA are preferred.
7. Computer literate and proficient in MS Office Applications.
8. Outstanding oral and written communication skills.
9. Strong ethics and a high level of personal and professional integrity.
10. Excellent customer service skills.
11. Effective team player and good interpersonal skills.
12. Supports organizational and departmental philosophy, objectives and goals.
13. Able to work independently and with minimal supervision.
14. Ability to prioritize and organize multiple tasks.
15. Capable of handling demands and time pressure workload.
16. Must be able to meet set deadlines and goals.
17. Ability to work on full time schedule including extended hours, weekends, and holidays.

Job Summary:

Reports directly to the Healthplan Finance Manager and performs analysis of claims based on medical necessity, approved coverage guidelines and appropriate coding and payment standards.  Responsible for analyzing On-island, and Off-island facility/institutional, ambulatory, surgical, diagnostic and other medical claims prior to payment.

Duties and Responsibilities:

1.  Claims Production

1. Reviews claims daily based on medical necessity, coverage guidelines, coding & payment standard and applicable regulatory and compliance requirements.
2. Reviews claims above $25,000 in estimated payments
3. Reviews services for appropriateness of charges and ensures payments are consistent with authorization information during claims processing.
4. Reviews and interprets medical records to determine appropriateness of care and its level, identifies any excessive & unchartered charges, non-covered or excluded services, services exceeding benefit limitation and appropriate application of benefit coverage. 
5. Ensures appropriate coding guidelines are applied to all claims prior to payment

2.  Quality

2.1 Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits, i.e., co-payments, deductibles, etc.

2.2 Responsible for maintaining a 98% claims processing accuracy rate.

2.3 Strict compliance of all HIPAA rules and regulations.

2.4 Ensures all Protected Healthcare Information (PHI) is secured.

3.  Customer Service

3.1. Responds to inquiries from internal departments and external providers in a timely and courteous manner based on any follow up questions and/or appeals on payments and/or coding issue. 

3.2. Responds and solves issues referred by the Customer Service Dept within 2-5 working days.

3.3. Resolve provider or physician group claims inquiries and executes resolution in a timely fashion.

4. Reporting

4.1. Creates and maintains a daily production report of all reviewed claims 

4.2. Updates and prepares reports for Management Team as required.

4.3. Informs and reports to Claims Team Lead, Claims Supervisor and/or Claims Manager issues that impact quality and claims payment accuracy.

4.4. Routinely updates milestones and goals within the performance goal system.

5. Performs other duties as assigned.