Claims Supervisor

Maxicare Healthcare Corporation; Cebu City; On-site; PHP 600,000 - 800,000; Full time

Job summary

Maxicare Healthcare Corporation in Cebu City is seeking a Claims Operations Lead to supervise the daily activities of the Claims team, ensuring accurate and timely outpatient claim processing.

You will review member coverage, provider billings, and apply company guidelines while coaching staff to meet SLA targets and quality standards, coordinating with stakeholders to resolve claims efficiently.

Responsibilities

• Supervise and oversee the daily operations of the Claims team to ensure efficient, accurate, and timely processing of outpatient claims.
• Review applicable member coverage, benefits, and limits based on account-specific provisions, internal guidelines, policies, and procedures.
• Review provider billings and validate applicable professional fees using approved reference rates and company guidelines.
• Analyze, review, approve, and process outpatient claims within the approved authority limit while ensuring compliance with established policies and procedures.
• Ensure the accuracy, completeness, and quality of all approved and validated claims within the prescribed processing guidelines, turnaround time (TAT), and service level agreements (SLAs).
• Monitor team productivity, quality, and compliance with operational standards, and implement corrective actions to address performance gaps.
• Respond to and resolve claims-related concerns, complex cases, and escalated issues from team members, providers, clients, and other internal departments.
• Ensure the timely processing and settlement of outpatient claims in accordance with agreed credit terms and reconciliation schedules.
• Escalate high-risk, exceptional, or complex claims issues to the Claims Manager and coordinate with relevant business units for resolution.
• Ensure the proper establishment, documentation, and endorsement of validated claims requiring financial recovery, investigation, or further action.
• Review and approve claim adjustments, reversals, and exceptions within delegated authority.
• Conduct regular coaching, performance monitoring, and feedback sessions to develop team members and improve overall performance.
• Provide technical guidance and mentoring to Claims Analysts and Associates on claims evaluation, policy interpretation, and process improvements.
• Prepare and analyze claims performance reports, productivity metrics, aging reports, and quality indicators, and recommend process improvements.
• Identify operational risks, process inefficiencies, and recurring claims issues, and recommend corrective and preventive actions.
• Ensure compliance with company policies, regulatory requirements, audit standards, and internal control procedures.
• Coordinate with Healthcare Providers, Customer Service, Finance, Medical Services, and other stakeholders to resolve claims-related concerns and improve service delivery.
• Participate in process improvement initiatives, system enhancements, policy updates, and projects that enhance claims operations and customer experience.
• Perform other duties and responsibilities that may be assigned by Management in support of Claims Operations.

Job description

Key Responsibilities

• Supervise and oversee the daily operations of the Claims team to ensure efficient, accurate, and timely processing of outpatient claims.

• Review applicable member coverage, benefits, and limits based on account-specific provisions, internal guidelines, policies, and procedures.

• Review provider billings and validate applicable professional fees using approved reference rates and company guidelines.

• Analyze, review, approve, and process outpatient claims within the approved authority limit while ensuring compliance with established policies and procedures.

• Ensure the accuracy, completeness, and quality of all approved and validated claims within the prescribed processing guidelines, turnaround time (TAT), and service level agreements (SLAs).

• Monitor team productivity, quality, and compliance with operational standards, and implement corrective actions to address performance gaps.

• Respond to and resolve claims-related concerns, complex cases, and escalated issues from team members, providers, clients, and other internal departments.

• Ensure the timely processing and settlement of outpatient claims in accordance with agreed credit terms and reconciliation schedules.

• Escalate high-risk, exceptional, or complex claims issues to the Claims Manager and coordinate with relevant business units for resolution.

• Ensure the proper establishment, documentation, and endorsement of validated claims requiring financial recovery, investigation, or further action.

• Review and approve claim adjustments, reversals, and exceptions within delegated authority.

• Conduct regular coaching, performance monitoring, and feedback sessions to develop team members and improve overall performance.

• Provide technical guidance and mentoring to Claims Analysts and Associates on claims evaluation, policy interpretation, and process improvements.

• Prepare and analyze claims performance reports, productivity metrics, aging reports, and quality indicators, and recommend process improvements.

• Identify operational risks, process inefficiencies, and recurring claims issues, and recommend corrective and preventive actions.

• Ensure compliance with company policies, regulatory requirements, audit standards, and internal control procedures.

• Coordinate with Healthcare Providers, Customer Service, Finance, Medical Services, and other stakeholders to resolve claims-related concerns and improve service delivery.

• Participate in process improvement initiatives, system enhancements, policy updates, and projects that enhance claims operations and customer experience.

• Perform other duties and responsibilities that may be assigned by Management in support of Claims Operations.