Claims Recon Analyst

Maxicare Healthcare Corporation; Cebu City; On-site; PHP 335,000 - 513,000; Full time

Job summary

Maxicare Healthcare Corporation seeks a Claims Reconciliation Specialist to review, reconcile, and pay reconciliation-required claims within target timelines. You will coordinate with Claims, Finance, and Provider Relations to resolve payment issues and improve processes, while maintaining meticulous documentation.

You will analyze trends, generate dashboards, and escalate complex matters when needed, ensuring accuracy and timely settlements with provider networks.

Qualifications

• Bachelor's degree in Business Administration, Accounting, Finance, Healthcare Management, or related field.
• Strong knowledge of claims processing, reconciliation, provider billing, and healthcare/HMO operations.
• Strong analytical, problem-solving, and decision-making skills.
• Excellent attention to detail and accuracy in handling financial and claims-related information.
• Strong communication and interpersonal skills, with the ability to coordinate with providers and internal stakeholders.
• Proficient in Microsoft Office, particularly Excel, and comfortable working with large data volumes.
• Ability to manage multiple requests, prioritize tasks, and meet turnaround times.

Responsibilities

• Review, reconcile, resolve, and pay claims identified for reconciliation within agreed timelines.
• Reconcile claims records between Maxicare and providers (hospitals, clinics, physicians, dentists) to identify variances.
• Maintain centralized monitoring report with status, actions, and resolutions.
• Coordinate with Claims, Finance, Provider Relations, and other units to resolve payment issues.
• Escalate complex issues to appropriate unit for resolution or approval.
• Request, validate, and secure Clearance Certificates from providers upon reconciliation completion.
• Analyze data and trends to identify root causes and opportunities for improvement.
• Recommend and implement solutions to minimize recurring errors and discrepancies.
• Develop strong relationships with healthcare providers to facilitate timely resolution.
• Prepare regular reports and dashboards on reconciliation activities and performance metrics.
• Monitor turnaround time and ensure compliance with SLAs, policies, and procedures.
• Maintain documentation of findings, correspondence, approvals, and settlement actions for audit.

Skills

Analytical skills

Attention to detail

Communication skills

Excel proficiency

Data analysis

Multitasking

Education

Bachelor's degree in Business Administration, Accounting, Finance, Healthcare Management, or related field

Tools

Microsoft Office

Excel

Job description

• Ensure the complete review, reconciliation, resolution, and payment of claims identified as requiring reconciliation, within the agreed turnaround time and settlement timelines.

• Reconcile claims records between Maxicare and healthcare providers, including hospitals, clinics, physicians, and dentists, to identify discrepancies, variances, and outstanding claims.

• Maintain accurate and updated information in the centralized monitoring report for all received reconciliation requests, including status, actions taken, and resolution.

• Coordinate closely with Claims, Finance, Provider Relations, and other concerned units to investigate and resolve payment issues and reconciliation concerns.

• Escalate complex or unresolved issues reported by providers to the appropriate unit or department for further handling, recommendation, or approval.

• Request, validate, and secure Clearance Certificates from providers upon completion of reconciliation and settlement requirements.

• Analyze claims data and reconciliation trends to identify recurring discrepancies, root causes, process gaps, and opportunities for improvement.

• Recommend and implement solutions to minimize recurring errors, payment discrepancies, and reconciliation issues.

• Develop and maintain strong working relationships with healthcare providers to promote open communication and facilitate timely resolution of reconciliation concerns.

• Prepare regular reports, dashboards, and presentations on reconciliation activities, aging, outstanding items, resolution status, and performance metrics for management review.

• Monitor reconciliation turnaround time and ensure compliance with established service-level agreements, policies, and procedures.

• Maintain complete and accurate documentation of reconciliation findings, correspondence, approvals, and settlement actions for audit and reference purposes.

• Serve as a subject matter expert on claims reconciliation processes and procedures and provide guidance and support to team members and relevant stakeholders.

• Identify opportunities to streamline reconciliation processes and improve operational efficiency, accuracy, and provider experience.

Experience

• 1-3 years of relevant experience in claims processing, claims reconciliation, healthcare insurance operations, provider billing, accounts reconciliation, or a related field.

• Experience handling healthcare claims and provider transactions, preferably within an HMO, health insurance, hospital, or healthcare organization.

• Demonstrated experience in investigating claims discrepancies, payment variances, outstanding claims, and reconciliation issues.

• Experience coordinating with internal departments and external healthcare providers to resolve complex claims and payment concerns.

• Experience preparing reconciliation reports, monitoring trackers, and management reports.

• Strong analytical experience, including the ability to identify trends, investigate root causes, and recommend corrective actions.

• Experience handling provider inquiries, escalations, and settlement documentation is an advantage.

Qualifications

• Bachelor's degree in Business Administration, Accounting, Finance, Healthcare Management, or a related field.

• Strong knowledge of claims processing, reconciliation, provider billing, and healthcare/HMO operations.

• Strong analytical, problem-solving, and decision-making skills.

• Excellent attention to detail and accuracy in handling financial and claims-related information.

• Strong communication and interpersonal skills, with the ability to effectively coordinate with providers and internal stakeholders.

• Proficient in Microsoft Office, particularly Excel, and comfortable working with large volumes of data and reconciliation reports.

• Ability to manage multiple requests, prioritize tasks, and meet agreed turnaround times.

• Strong organizational and documentation skills.

• Ability to handle sensitive claims and payment information with confidentiality and professionalism.

• Knowledge of healthcare insurance/HMO policies, claims procedures, and provider settlement processes is preferred.