Claims Examiner Senior Specialist

Tenet Global Business Center, Inc.; Quezon City; On-site; PHP 300,000 - 600,000; Full time

Job summary

Tenet Global Business Center, Inc. is seeking an experienced claims reviewer to ensure accurate and timely review of complex claims in line with contracts, regulations, health plan requirements, policies and procedures, and generally accepted business practices.

You will analyze professional and hospital claims, review provider contracts, handle correspondence, and support customer service with escalated issues in a fast-paced managed care environment.

Qualifications

• Experience with general office equipment and Windows PC environments.
• Strong understanding of health and managed care concepts in claims adjudication.
• Proficient in ICD-9-CM, CPT, HCPCS, RBRVS coding and medical terminology.

Responsibilities

• Analyzes professional and hospital claims for accuracy per thresholds and quality standards.
• Reviews authorization and provider contracts and adjudicates claims accordingly.
• Handles correspondence, follow-up, and projects assigned by claims supervisor.
• Supports customer service with escalated member issues.

Skills

Office equipment experience

Health care concepts

Medical coding knowledge

Job description

JOB SUMMARY

Responsible for the accurate and timely review of complex claims in accordance with applicable contracts, state and federal regulations, health plan requirements, policies and procedures, and generally accepted business practices.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Analyzes professional and hospital claims for accuracy according to set dollar thresholds and meets and maintains production and quality standards

• Reviews authorization and/or provider's contract and adjudicates claims accordingly.

• Perform any correspondence, follow-up and any projects delegated by claims supervisor.

• Provide assistance to the customer service department with escalated member issues.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• General office equipment experience (i.e. photocopier, fax, calculator, ability to operate a PC and previous exposure to the Microsoft Windows environment).

• Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims.

• Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology.

EXPERIENCE

• 2-3 years claims experience in a managed care environment.

• 3-5 years claims processing UB-04 and professional experience.

• 3-5 years Medicare, Medicaid, Medical, Commercial, PPO and HMO claims experience.