Clinical Claims & Adjudication Specialist

Seven Seven Six; Philippines; On-site; PHP 600,000 - 900,000; Full time

Job summary

Seven Seven Six in the Philippines seeks a clinically experienced professional to support health insurance claims adjudication and coding guidance. You will translate clinical terminology into actionable guidance on ICD-10, CPT, and local coding standards, serving as a resource for claims assessment and configuration.

You will review medical necessity, appropriateness of care, and documentation, collaborate with claims, medical, and operations teams, and help ensure compliance with internal

Qualifications

• MD/MBBS or Nurse with significant clinical experience.
• At least 3 years in health insurance, hospital case management, or medical claims.
• Familiarity with local healthcare practices and provider behaviors.
• Strong knowledge of medical coding (ICD-10, CPT) and documentation.

Responsibilities

• Translate clinical terminology into claims adjudication and coding guidance.
• Provide guidance on ICD-10, CPT, or local coding standards.
• Offer clinical input on medical necessity, appropriateness of care, and treatment pathways.
• Review pre-authorizations and guarantee-of-payment requests.
• Collaborate with claims, medical, and operations teams on complex cases.

Skills

Clinical knowledge

Medical coding

Stakeholder communication

Analytical thinking

Education

MD/MBBS or Nurse

Pharmacy or Allied Health

Job description

Seven Seven Six in the Philippines seeks a clinically experienced professional to support health insurance claims adjudication and coding guidance. You will translate clinical terminology into actionable guidance on ICD-10, CPT, and local coding standards, serving as a resource for claims assessment and configuration.

You will review medical necessity, appropriateness of care, and documentation, collaborate with claims, medical, and operations teams, and help ensure compliance with internal