Claims Strategy & Service Lead

PERSOL; Santo Niño 1st; On-site; PHP 400,000 - 650,000; Full time

Job summary

PERSOL is seeking a Claims Assessment professional in the Philippines to assess medical claims, manage investigations and appeals, and ensure compliant, timely payouts. The role emphasizes accuracy, stakeholder collaboration, and strong communication with policyholders and medical professionals.

The ideal candidate holds a degree or insurance certificate with at least 3 years of medical claims experience and a demonstrated ability to interpret complex medical data while maintaining high-quality

Qualifications

• Bachelor's degree or Professional Insurance Certificate or related discipline.
• At least 3 years of experience in medical claims.
• Strong grasp of medical practices, terminology, ICD/CPT codes, and insurance policy terms.
• Strong analytical skills to interpret complex medical data, spot trends, and make sound decisions under pressure.
• Detail-oriented with a proven track record of managing high processing volumes without compromising quality.
• Customer-focused with excellent ability to build relationships with stakeholders and provide clear, empathetic communication.
• Team player who learns quickly in a fast-paced, collaborative environment.

Responsibilities

• Assess integrated shield claims and appeals accurately and within established service standards to ensure timely and correct claim payments.
• Manage claim investigations and appeals, including reviewing medical documentation and policy terms.
• Conduct review of pending claims to ensure reserve adequacy and closure of claims in a timely manner.
• Identify claim patterns and unusual or inappropriate practices and recommend improvements to strengthen claims controls and streamline claim processes.
• Collaborate with medical institutions, policyholders, and internal stakeholders to gather and clarify clinical information or outstanding requirements.
• Deliver high standards of customer service and strengthen relationships with customers and distribution channels.
• Deliver accurate and timely assessment of medical claims, ensuring fair payouts in line with service standards and policy terms.
• Provide clear, empathetic communication to policyholders, medical professionals, and internal stakeholders, making the claims process smooth and transparent.
• Adhere to internal policies and external regulatory requirements to maintain integrity and trust in claims operations.
• Take accountability for risk management and keep aware of regulatory trends.

Skills

Analytical skills

Attention to detail

Communication

Team player

Integrity

Education

Bachelor's degree

Professional Insurance Certificate

Job description

PERSOL is seeking a Claims Assessment professional in the Philippines to assess medical claims, manage investigations and appeals, and ensure compliant, timely payouts. The role emphasizes accuracy, stakeholder collaboration, and strong communication with policyholders and medical professionals.

The ideal candidate holds a degree or insurance certificate with at least 3 years of medical claims experience and a demonstrated ability to interpret complex medical data while maintaining high-quality