HDSI: Claims Processor Analyst

ActiveOne Health, Inc.; Mandaluyong; On-site; PHP 300,000 - 420,000; Full time

Job summary

ActiveOne Health, Inc. is seeking a Claim Processor in Metro Manila to ensure timely and accurate processing of employee benefit claims, including FlexBen and health benefit administration.

The role involves reviewing documentation, data entry, verifying eligibility, and determining coverage based on plan guidelines. The incumbent will communicate with other departments on issues, address exceptions, and adhere to SLA expectations while working onsite at mandaluyong facilities.

Qualifications

• Bachelor's/College Degree in health or medical allied courses such as Nursing, Pharmacy, etc.
• At least 2 years of solid working experience in claims processing or related field.
• Experience in TPA, HMO, insurance, or insurance broker environments is preferred.

Responsibilities

• Capture claim data accurately into the claims management system and maintain records of all claim transactions and outcomes.
• Analyze claims for completeness, accuracy, and compliance with member plan terms.
• Confirm member eligibility for benefits and verify coverage under the plan.
• Adjudicate and authorize payments or escalate to other parties for review as needed.
• Investigate discrepancies by gathering information from members and other stakeholders.
• Inform employees on progress of their claims per SLA and agreed processes.
• Respond to inquiries or complaints following the SLA and working arrangements.

Skills

Data entry

Claims adjudication

Eligibility verification

Interdepartmental communication

Education

Bachelor's/College Degree in health and allied fields

Tools

Claims management system

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:

1. Accurately captures claim data into the claims management system and maintains updated records of all claim transactions, communications, and outcomes.


2. Analyze claims for completeness, accuracy, and compliance with the specific terms of the member’s benefit plan.


3. Confirm the member’s eligibility for benefits and verify that the services or expenses are covered under their current plan.


4. Adjudicate and authorize the appropriate payment or refer/escalate claims to concerned parties for further review.


5. Investigate and resolve discrepancies, errors, and issues related to eligible benefits by gathering additional information from the members, other departments, and other stakeholders.


6. 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.


7. Respond to employees’ inquiries or complaints based on the agreed ways of working and SLA.

Background and Qualifications:

1. Candidates must possess at least a Bachelor's/College Degree preferably in health / medical allied courses such as Nursing, Pharmacy, etc.


2. At least 2 year(s) of solid working experience in the related field is required for this position.


3. With experience working in TPA, HMO, insurance or insurance broker companies.


4. Ability to work onsite and extend beyond company operating hours when needed.

Pursuant to the Data Privacy Act of 2012 (R.A. 10173), its Implementing Rules and Regulations, and other issuances of the National Privacy Commission, the RelianceCare Inc., OR it's subsidiary or affiliate, such as ActiveOne Health, Inc., and Health Delivery Systems, Inc. (also doing business under the name and style of "Flexicare Benefit Solutions and Healthfirst Clinic"), whichever is applicable to this form, ("It" or "the Company", for brevity) commits to protect and keep the confidentiality, integrity, and availability of all personal data provided. It will only use personal information to process job applications. Any questions regarding the Company's privacy notice shall be coursed through Its Data Protection Officer at the following and applicable email addresses: RCI -••••@reliancehealth.com.ph, ActiveOne -••••@activeonehealth.com, or HDSI -••••@healthfirst.com.ph