Benefit Claims Adjudication Specialist

ActiveOne Health, Inc.; Mandaluyong; On-site; PHP 300,000 - 420,000; Full time

Job summary

ActiveOne Health, Inc. is seeking a Claim Processor in Metro Manila to ensure timely and accurate processing of employee benefit claims, including FlexBen and health benefit administration.

The role involves reviewing documentation, data entry, verifying eligibility, and determining coverage based on plan guidelines. The incumbent will communicate with other departments on issues, address exceptions, and adhere to SLA expectations while working onsite at mandaluyong facilities.

Qualifications

• Bachelor's/College Degree in health or medical allied courses such as Nursing, Pharmacy, etc.
• At least 2 years of solid working experience in claims processing or related field.
• Experience in TPA, HMO, insurance, or insurance broker environments is preferred.

Responsibilities

• Capture claim data accurately into the claims management system and maintain records of all claim transactions and outcomes.
• Analyze claims for completeness, accuracy, and compliance with member plan terms.
• Confirm member eligibility for benefits and verify coverage under the plan.
• Adjudicate and authorize payments or escalate to other parties for review as needed.
• Investigate discrepancies by gathering information from members and other stakeholders.
• Inform employees on progress of their claims per SLA and agreed processes.
• Respond to inquiries or complaints following the SLA and working arrangements.

Skills

Data entry

Claims adjudication

Eligibility verification

Interdepartmental communication

Education

Bachelor's/College Degree in health and allied fields

Tools

Claims management system

Job description

ActiveOne Health, Inc. is seeking a Claim Processor in Metro Manila to ensure timely and accurate processing of employee benefit claims, including FlexBen and health benefit administration.

The role involves reviewing documentation, data entry, verifying eligibility, and determining coverage based on plan guidelines. The incumbent will communicate with other departments on issues, address exceptions, and adhere to SLA expectations while working onsite at mandaluyong facilities.