CLAIMS PROCESSOR

Job Qualifications:

Must be a graduate of any medical related course

Computer Literate

Must be willing to work in Makati

Male / Female with pleasing and strong personality

Job Description:

This job is responsible for the review, analysis and/or adjudication of claims incurred by eligible members of Health Insurance to ensure that they are according to respective benefits plan, policies and standards and maintain the records system for these claims.

Ensures accurate review of claims document like LOA, hospital bills/SOA, concurrent review form, physician’s report, original OR for use in processing claims

Checks on completeness of received claims documents

Reviews and match the endorsed document against ha actual encoded data in the system

Reviews/evaluates claims and adjudicates claims to ensure claims are according to benefits plan, coverage and policies and standards.

Reviews, evaluates. checks and/or adjudicates claims against ABC, CQS and utilization and existing company policies and procedures for coverage and effectivity of plan

Accurately evaluates and process Outpatient and In-patient claim reimbursement and non-reimbursement,received from various providers and meet the required quota.

Approves claims according to limits of authority.

Ensures provision of quality customer service

Maintains good relationships with providers by making regular visits and ensuring timely payment of medical bills, in coordination with other departments.

Handles inquiries of clients, members and agents regarding application for claims, including handling complaints.

Undertakes Administrative Responsibilities to ensures proper filing of claims documentation and booking them.

Makes accounting entries to book claims transactions

Logs and files documents and transmittal of released comments

Turns over all processed claims transactions to the Records Room

Maintains computerized system used in processing claims thru timely, accurate capturing, recording and dissemination of claims information

Prepares Management Reports on claims