Claims Specialist

Dempsey Resource Management Inc.; Makati; On-site; PHP 182,800 - 218,959; Full time

Job summary

A human resource management firm in Makati is seeking a Claims Processor/Analyst to handle medical claims processing. Responsibilities include reviewing claims for accuracy and completeness, data entry, and evaluating claims against policy provisions. Ideal candidates have a related degree and experience in claims processing, with strong analytical and communication skills. Competitive salary offered at PHP 18,000 per month.

Qualifications

• 1-2 years of relevant experience in medical claims processing or administrative support in healthcare.
• Familiarity with medical billing and reimbursement processes.
• Experience working with HMO procedures is a plus.

Responsibilities

• Review and process medical claims submitted by members or healthcare providers.
• Encode claims data into the medical claims processing system.
• Evaluate claims against policy provisions and clinical guidelines.

Skills

Attention to details

Analytical thinking

Communication

Technical proficiency

Problem-solving

Education

Bachelor’s degree in Business administration, Healthcare Management, Nursing, or related field

Diploma in medical, healthcare, or business-related field

Tools

Medical claims processing systems

Microsoft Excel

MS Word

Job description

Claims Processing

• Review and process medical claims submitted by members or healthcare providers.


• Check documents for completeness, including medical abstracts, itemized statements, and official receipts.


• Verify member eligibility, benefits coverage, and policy limits.


• Apply appropriate coding and benefits computation based on the member’s plan and HMO rules.

Data Entry & Record Keeping

• Encode claims data into the medical claims processing system.


• Maintain updated records of approved, denied, and pending claims.


• Document any adjustments, follow-ups, and discrepancies.

Claims Evaluation

• Evaluate claims against policy provisions and clinical guidelines.


• Detect potential fraud, abuse, or claim duplication.


• Coordinate with medical providers to validate unclear or questionable claims.


• Accurately calculate payable amounts, co-pays, and exclusions.

Job Position: CLAIMS PROCESSOR/ANALYST

Monthly Salary: PHP 18,000

Work Schedule: Monday to Friday

Working Hours: 8:30 am to 5:30 pm

Work Location: Makati Office

Job Qualifications

• Educational Background:


• Bachelor’s degree in Business administration, Healthcare Management, Nursing, or a related field is preferred.


• A diploma in medical, healthcare, or business-related field may be considered.

• Experience:


• 1-2 years of relevant experience in medical claims processing or administrative support in healthcare, hospitals, clinics, or insurance/HMO industries.


• Familiarity with medical billing and reimbursement processes.


• Experience working with HMO procedures and healthcare provider networks is a plus.

• Skills:


• Attention to Details: Accurate and thorough in reviewing medical claims, documents, and codes.


• Analytical Thinking: Ability to interpret policy coverage, medical reports, and supporting documents to identify discrepancies or irregularities.


• Communication: Strong written and verbal communication skills to coordinate with hospitals, clinics, and policyholders.


• Technical Proficiency: Proficient in medical claims processing systems, Microsoft Excel, MS Word, and email platforms.


• Problem-solving: Capable of investigating claims issues and resolving them in a timely and efficient manner.

• Other Qualifications:


• Familiarity with ICD, CPT, and HCPCS codes and medical terminology.


• Knowledge of insurance guidelines, HMO processes, and regulatory compliance.


• Ability to multitask and work efficiently under time constraints.


• Excellent organizational and documentation skills.