HDSI: Claims Processor Analyst

ACTIVEONE HEALTH, INC.; Mandaluyong; On-site; PHP 300,000 - 450,000; Full time

Job summary

ACTIVEONE HEALTH, INC. is looking for Claim Processors responsible for the timely processing of employee benefit claims related to flexible benefits and health benefit administration. This role involves data entry and verification of eligibility based on plan guidelines.

The ideal candidate must possess a Bachelor's degree in health or medical allied courses and have at least two years of relevant experience. Strong communication skills and the ability to work onsite are essential for this position.

Qualifications

• At least 2 years of experience in claims processing or related field.
• Experience in TPA, HMO, or insurance companies is preferred.
• Ability to work onsite and beyond operating hours when necessary.

Responsibilities

• Process and adjudicate employee benefit claims accurately.
• Verify member eligibility and coverage under the plan.
• Respond to employee inquiries about their claims.

Skills

Data entry accuracy

Claim analysis

Communication

Eligibility verification

Education

Bachelor's/College Degree in health/medical allied courses

Job description

Job Objective

Claim Processors are responsible for timely and accurate processing and adjudication of employee benefit claims, related to flexible benefits (FlexBen) and/or health benefit administration (HBA) programs. This role involves reviewing submitted documentation, performing data entry, verifying eligibility, and determining coverage based on plan guidelines. Communicate with issues or exceptions to other concerned departments as necessary.

Duties and Responsibilities

• Accurately captures claim data into the claims management system and maintains updated records of all claim transactions, communications, and outcomes.
• Analyze claims for completeness, accuracy, and compliance with the specific terms of the member’s benefit plan.
• Confirm the member’s eligibility for benefits and verify that the services or expenses are covered under their current plan.
• Adjudicate and authorize the appropriate payment or refer/escalate claims to concerned parties for further review.
• Investigate and resolve discrepancies, errors, or issues related to eligible benefits by gathering additional information from the members, other departments, and other stakeholders.
• Inform employees on the progress of their claims (e.g., pending for review, with missing attachment, or for crediting) based on the agreed ways of working and SLA.
• Respond to employees’ inquiries or complaints based on the agreed ways of working and SLA.

Background and Qualifications

• Candidates must possess at least a Bachelor's/College Degree preferably in health / medical allied courses such as Nursing, Pharmacy, etc.
• At least 2 year(s) of solid working experience in the related field is required for this position.
• With experience working in TPA, HMO, insurance or insurance broker companies.
• Ability to work onsite and extend beyond company operating hours when needed.