Senior Claims Specialist (Cebu)

• Competitive rewards with 13th and 14th month pay
• Comprehensive health insurance including life insurance and accident insurance
• Retirement benefits
• Annual medical allowance to support wellness needs
• Generous leave entitlements: vacation leave, sick leave, and emergency leave

Duties and Responsibilities:

• Checks availability and accuracy of claims details in MAS
• Makes necessary corrections of claims details
• Verifies unlisted claims in MAS with biller and Call Center
• Processes and analyze claims using the prescribed process and based on existing policy contract and guidelines
• Prepares transmittal of claims for payment
• Approves payment for claims within the authority limit]
• Recommends approval of claims payment beyond authority limit
• Reconcile claims with providers/accounts
• Conduct UAT of system enhancements
• Provide analysis and findings on the UAT done
• Coordinate with ITG on the findings
• Answer inquiries via email or phone regarding status of claims or overdue payments within set turn-around time
• Documentation of medical claims disputes or complaints
• Resolution or escalation of claims disputes or complaints within the TAT
• Coordination with sales and other work units on claims or non-claims related customer concerns received via email or phone
• Reconciles statement of account (SOA) sent by providers
• Coordinate with concerned departments on the items subject of reconciliation
• Coordinate with the provider contact person to discuss issues or requests
• Release of reconciled account within SLA

• Education: College graduates with a degree in any medical or business-related discipline
• At least two (2) years’ experience in medical or life claims processing
• Preferably passed Life Office Management Association (LOMA) courses