Micro HMO Claims Specialist

Pioneer Your Insurance; Cebu City; On-site; PHP 279,000 - 446,000; Full time

Job summary

Pioneer Your Insurance in Cebu City is seeking a Claims Associate to support management of the department's loss ratio by evaluating simple claims and flagging suspicious cases, ensuring fair settlements for customers and the company. You will deliver services by meeting SLAs, following established procedures, and contributing to efficient claims management and provider billing settlements.

Ideal candidates have a Bachelor's degree in related field, 1–2 years claims experience, and proficiency

Qualifications

• Bachelor's degree in related field.
• 1–2 years experience in claims processing or HMO admin tasks.
• Knowledge of HMO/insurance claims procedures and medical terminology advantageous.
• Proficient in MS Office (Excel, Word, Outlook).
• Strong attention to detail and accuracy in reviewing documents.

Responsibilities

• Contributes to loss ratio management by evaluating simple claims cases and handling detected suspicious or fraudulent cases according to established standards.
• Delivers efficient service by meeting SLAs and following procedures to improve customer experience.
• Performs claims management (reimbursement) and provider billing settlements as required.
• Resolves simple concerns within their function and escalates issues to maintain SLAs.
• Provides accurate data or completes assigned reports per specifications and guidelines.

Skills

MS Office

Attention to detail

Communication skills

Customer service

Claims processing

Languages: English/Tagalog/Bisaya

Education

Bachelor's degree in Business Administration, Healthcare Administration, Nursing, Medical Allied Courses, or related field

Tools

Provider Billing System

Job description

YOUR ROLE:

• Contributes to the management of the department's loss ratio by evaluating simple claims cases and handling detected suspicious or fraudulent cases according to the established claims standards and guidelines of the department and Pioneer Group to ensure that claims settlements are fair for both our customers and Pioneer at all times.

• Contributes to the efficient delivery of services to customers by meeting SLAs, complying with established standards, guidelines, and procedures, and seeking guidance to improve their efficiency with the end-goal of improving the overall customer experience.

• Fulfills the following processes and activities consistently according to agreed-upon quality standards and turn-around time:
  a. Claims Management (Reimbursement)
  b. Provider Billing Settlement

• Resolves simple concerns within their function efficiently and escalates issues as needed to maintain established Service Level Agreements (SLAs).

• Provides accurate data or completes assigned reports according to specifications while observing the SLA and the data and document management standards and guidelines.

A bit about you:

• Bachelor's degree in Business Administration, Healthcare Administration, Nursing, Medical Allied Courses, or any related field.

• At least 1–2 years of experience in claims processing, HMO in general and administrative task.

• Knowledge of HMO/insurance claims procedures, healthcare benefits, and medical terminology is an advantage.

• Proficient in Microsoft Office applications, particularly Excel, Word, and Outlook.

• Strong attention to detail and accuracy in reviewing and processing documents.

• Can speak english, bisaya and tagalog

What we need:

• Strong communication and people skills

• Comfortable working in a fast-paced environment

• Strong organizational skills

• Attention to detail

• Passion in customer service