Claims Analyst

TakeCare Asia Philippines, Inc.; Manila; Presencial; PHP 290.000 - 424.000; Jornada completa

Descripción de la vacante

TakeCare Asia Philippines, Inc. is seeking a Claims Production professional to review and adjudicate medical claims, ensuring payments align with authorization, guidelines, and coding standards.

You will analyze records, maintain accuracy targets, adhere to HIPAA, and generate daily production reports for management; collaboration with Customer Service and Claims teams to resolve inquiries and improve turnaround times.

Formación

• Reviews claims daily based on medical necessity and guidelines.
• Prepares and adjudicates claims with accurate procedure/revenue and ICD-10 codes.
• Maintains a 98% claims processing accuracy rate.
• Strict compliance with HIPAA rules and protections of PHI.

Responsabilidades

• Analyze, process, adjust, and adjudicate claims with correct codes under provider and member benefits.
• Respond to inquiries from internal departments and external providers in a timely and courteous manner.
• Resolve provider or physician group claims inquiries and document resolutions.
• Create and maintain a daily production report of all reviewed claims and update management.

Descripción del empleo

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.

1. 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.

1. 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.

1. Performs other duties as assigned.