CLAIMS MANAGER

Value Care Health Systems, Inc; Pasig; On-site; PHP 1,500,000 - 2,300,000; Full time

Job summary

Value Care Health Systems, Inc. seeks a seasoned Claims Manager to lead end-to-end medical claims operations, ensuring accurate adjudication, compliance, and cost containment.

You will drive process improvements, governance, and provider relationships while managing fraud prevention initiatives and performance analytics. With 10+ years in HMO/healthcare claims and 5+ years in leadership, you will guide a team toward high-quality outcomes, collaborating with hospitals, clinics, and providers in a

Qualifications

• Bachelor's degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Healthcare Administration, Business Administration, or similar allied fields.
• Master's degree in Business Administration or Healthcare Administration is advantageous.
• Minimum 10 years in HMO Claims Management, Health Insurance Operations, or Healthcare Administration.
• At least 5 years in a managerial or senior leadership role overseeing end-to-end claims operations.
• Strong background in medical claims adjudication, provider billing, and reimbursement.

Responsibilities

• Lead end-to-end claims operations, ensuring accurate and timely adjudication.
• Develop operational strategies to improve turnaround time while maintaining quality and compliance.
• Oversee provider billing, reconciliation, and cost-containment initiatives.
• Manage hospital and provider relationships, including investigations of questionable billing practices.
• Develop fraud detection strategies and coordinate with Legal and Compliance on cases.
• Establish quality standards for claims adjudication and drive continuous improvement.
• Develop dashboards and analytics to monitor volume, productivity, and trends.
• Coach and develop Supervisors and Team Leaders; drive a customer-centric culture.

Skills

Data analytics

Dashboard reporting

Stakeholder management

Negotiation

Communication skills

Microsoft Office Suite

Provider relationship management

Education

Bachelor's degree in Nursing/Healthcare Administration

Master's degree in Business Administration/Healthcare Administration

Tools

Claims processing platforms

Workflow systems

Billing reconciliation systems

ICD-10 and CPT coding knowledge

Job description

Job Overview

The Claims Manager leads, directs, and oversees the overall operations, strategic direction, governance, and performance of the Claims Department, ensuring the timely, accurate, compliant, and cost-effective processing of healthcare claims while maintaining strong and productive relationships with accredited hospitals, physicians, clinics, laboratories, and other healthcare providers.

The position manages and supervises end-to-end claims operations, including medical claims adjudication, claims validation, provider billing, reconciliation, payment processing, provider suspension and reinstatement activities, cost containment initiatives, fraud prevention, quality assurance, regulatory compliance, and continuous process improvement. The role develops and implements operational strategies, ensures adherence to company policies and regulatory requirements, drives operational excellence, mitigates financial and compliance risks, and promotes high standards of customer service, efficiency, and claims management effectiveness.

Job Responsibilities

1. Claims Operations Management

• Leads and oversees the end-to-end medical claims management process, ensuring accurate, timely, and efficient adjudication of all healthcare claims.
• Develops operational strategies that improve claims turnaround time while maintaining high standards of quality and compliance.
• Ensures claims are processed based on member eligibility, benefit schedules, medical necessity, contract provisions, company policies, provider agreements, and regulatory requirements.

2. Medical Claims Adjudication & Cost Management

• Ensures accurate interpretation of benefit limits, exclusions, co-payments, deductibles, room and board limits, professional fee schedules, and special approvals.
• Leads initiatives on claims leakage prevention, duplicate claims detection, overpayment recovery, underpayment correction, and medical cost containment.
• Identifies abnormal utilization patterns.
• Implements medical claims audit programs

3. Provider Billing & Reconciliation Management

• Ensures timely reconciliation of hospital statements of accounts, physician professional fees, and diagnostic center/clinic billings.
• Ensures accurate matching between LOAs, claims, hospital billing records, approved benefits, and payment records.
• Ensures aging reconciliation accounts are resolved within target timelines.
• Develops reconciliation dashboards and monitoring tools.

4. Hospital & Provider Relationship Management

• Leads and represents the company in investigations and meetings involving hospitals, clinics, physicians, laboratories, and other healthcare providers concerning claims issues and questionable billing practices.
• Evaluates providers for possible suspension due to fraudulent claims, excessive billing, unnecessary procedures, duplicate charging, misrepresentation, policy violations, and abuse of accreditation agreements.

5. Fraud Prevention & Claims Investigation

• Develops fraud detection strategies.
• Monitors trends involving provider fraud, member fraud, internal fraud, and claims manipulations.
• Coordinates with Legal and Compliance on fraud cases.
• Implements preventive controls.

6. Claims Quality Assurance

• Develops quality standards for claims adjudication.
• Monitors claims accuracy, processing consistency, documentation completeness, and policy compliance.
• Implements corrective action plans.
• Leads continuous quality improvement initiatives.

7. Performance Monitoring & Analytics

• Develops Claims Operations Dashboards.
• Monitors claims volume, productivity, backlogs, aging inventory, provider turnaround time, financial exposure, and claims trends.
• Recommends operational improvements based on analytics via monthly report to the management.

8. People Management

• Leads, coaches, mentors, and develops Supervisors and Team Leaders.
• Establishes workforce planning strategies.
• Conducts performance coaching sessions.
• Promotes accountability and a customer-centric culture.

Job Qualifications:

• Bachelor’s Degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Healthcare Administration, Business Administration, or other allied medical sciences.
• Master’s Degree in Business Administration, Healthcare Administration, Hospital Administration, or Management is an advantage.
• Minimum 10 years of progressive experience in HMO Claims Management, Health Insurance Operations, or Healthcare Administration.
• At least 5 years in a managerial or senior leadership role overseeing end-to-end claims operations.
• Extensive experience in medical claims adjudication, provider billing, reconciliation, and healthcare reimbursement.
• Strong background in provider accreditation governance, fraud investigation, and hospital/provider suspension management.
• Technical Knowledge: Medical Claims Processing, Healthcare Benefits Administration, HMO Reimbursement Methodologies, ICD-10 and CPT coding principles (preferred), PhilHealth coordination of benefits, Medical billing and provider payment systems, Provider contracts and accreditation standards, Healthcare fraud detection and investigation, Claims adjudication platforms and workflow systems
• Microsoft Office Suite (Excel, Word, PowerPoint)
• Data analytics and dashboard reporting
• Excellent decision-making, analytical, and communication skills
• Highly collaborative with strong stakeholder management and negotiation abilities
• Willing to work full on-site in Pasig City