Benefits Claims Specialist: Adjudication & Eligibility

Reliance United; Manila, Hinoba-an; On-site; PHP 360,000 - 480,000; Full time

Job summary

Reliance United is seeking a Claims Processor to ensure timely and accurate processing of employee benefit claims for FlexBen and health benefit programs. You will review submitted documents, perform data entry, verify eligibility, and determine coverage according to plan guidelines.

The role requires clear communication with other departments, adjudication or escalation of payments, and onsite availability to extend hours when needed.

Qualifications

• Bachelor's/College degree in health or medical allied fields.
• Minimum 2 years of experience in claims processing or related field.
• Experience in TPA, HMO, insurance or broker environments.
• Willingness to work onsite and extend beyond hours when needed.

Responsibilities

• Accurately captures claim data into the claims management system and maintains updated records of all claim transactions, communications, and outcomes.
• Analyze claims for completeness, accuracy, and compliance with the terms of the member’s benefit plan.
• Confirm member eligibility for benefits and verify coverage under the current plan.
• Adjudicate and authorize payments or refer/escalate claims for further review.
• Investigate and resolve discrepancies or issues by gathering information from members and stakeholders.
• Inform employees on claim progress and respond to inquiries per SLA.
• Respond to employees’ inquiries or complaints as per SLA.

Skills

Data entry

Claims processing

Communication

Analytical thinking

Education

Bachelor's degree in health/medical allied fields

Job description

Reliance United is seeking a Claims Processor to ensure timely and accurate processing of employee benefit claims for FlexBen and health benefit programs. You will review submitted documents, perform data entry, verify eligibility, and determine coverage according to plan guidelines.

The role requires clear communication with other departments, adjudication or escalation of payments, and onsite availability to extend hours when needed.