HDSI: Claims Processor Analyst

Reliance United; Manila, Hinoba-an; On-site; PHP 360,000 - 480,000; Full time

Job summary

Reliance United is seeking a Claims Processor to ensure timely and accurate processing of employee benefit claims for FlexBen and health benefit programs. You will review submitted documents, perform data entry, verify eligibility, and determine coverage according to plan guidelines.

The role requires clear communication with other departments, adjudication or escalation of payments, and onsite availability to extend hours when needed.

Qualifications

• Bachelor's/College degree in health or medical allied fields.
• Minimum 2 years of experience in claims processing or related field.
• Experience in TPA, HMO, insurance or broker environments.
• Willingness to work onsite and extend beyond hours when needed.

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 terms of the member’s benefit plan.
• Confirm member eligibility for benefits and verify coverage under the current plan.
• Adjudicate and authorize payments or refer/escalate claims for further review.
• Investigate and resolve discrepancies or issues by gathering information from members and stakeholders.
• Inform employees on claim progress and respond to inquiries per SLA.
• Respond to employees’ inquiries or complaints as per SLA.

Skills

Data entry

Claims processing

Communication

Analytical thinking

Education

Bachelor's degree in health/medical allied fields

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.