Hospital Claims Specialist - Potential WFH after Training

Hospital Claims Specialist - Potential WFH after Training
Location: Makati
Employment Type: Full-time
Work Setup: Onsite for the first 6 months, with potential work-from-home eligibility thereafter based on performance and business needs
THIS IS AN URGENT HIRING! We will prioritize those who can commit and start ASAP.
About the Role
We are looking for a highly experienced Hospital Claims Specialist with strong hands-on expertise in US healthcare facility claims adjudication. This role is ideal for a candidate who has worked in a payer, TPA, or managed care environment and can independently review, analyze, and resolve complex hospital claims with accuracy, consistency, and sound judgment.
The ideal candidate has deep knowledge of institutional billing, hospital reimbursement methodologies, and policy-based claim decision-making, and is confident handling complex inpatient and outpatient claims while meeting productivity, quality, and compliance standards.
Key Responsibilities:
Hospital Claims Adjudication
Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, ancillary, Home Health, and SNF claims, in accordance with benefit plans, policies, and standard procedures.
Validate claim accuracy and completeness, including:
member eligibility and cost share
provider affiliation and reimbursement
code validity
dates of service
authorization and referral requirements
supporting documentation
Make accurate claim determinations to pay, deny, adjust, pend, or contest claims, supported by proper rationale and documentation.
Apply member cost share correctly, including deductibles, copayments, coinsurance, benefit limits, and coordination of benefits (COB).
Identify payment integrity issues such as duplicate billing, coding discrepancies, billing errors, and policy inconsistencies.
Investigation & Complex Claim Resolution
Research and resolve
pended, high-dollar, high-risk, or complex hospital claims through analysis of system data, claim history, itemized bills, clinical records, and authorization details.
Exercise sound judgment in reviewing claims that require deeper investigation and independent decision-making.
Identify unclear policy interpretation, configuration gaps, and system-related issues, then escalate with clear findings and recommendations.
Documentation, Compliance & Quality
Maintain clear, complete, and audit-ready claim notes to support all claim decisions.
Ensure adherence to HIPAA, PHI privacy standards, internal controls, and regulatory requirements.
Participate in quality reviews, calibrations, and continuous improvement initiatives to reduce errors and improve accuracy.
Support internal and external audits by providing documentation and explanation of claim decisions when needed.
Required Qualifications
At least 5 years of hands-on experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting.
Strong working knowledge of institutional billing, including UB-04 and 837I claim formats.
Proven experience handling inpatient, outpatient, emergency room, Home Health, and SNF claims, including complex cases.
Solid understanding of:
DRG / APR-DRG reimbursement methodologies
Medicare and Medi-Cal claims processing
prior authorization and referral requirements
eligibility and benefits
timely filing rules
coordination of benefits
overpayment and underpayment identification
Ability to independently interpret:
provider contracts and reimbursement terms
payer policies
benefit summaries
claims processing guidelines
Strong analytical skills, attention to detail, and sound judgment.
Experience handling complex denials, pricing logic, payment integrity review, and high-dollar institutional claims is highly preferred.
Familiarity with payer platforms and claims adjudication systems.
Clear and confident English communication skills, including the ability to write concise and defensible claim notes.
Preferred Qualifications
Experience supporting Commercial, Medicare Advantage, or Medicaid plans.
Familiarity with appeals, reconsiderations, or provider dispute resolution.
Working knowledge of DRG and APC concepts, readmission logic, medical necessity indicators, and post-payment review.
Experience in a productivity- and quality-driven BPO or shared services environment.
Technical Knowledge Required
Claims & Coding Knowledge
Strong understanding of CPT, HCPCS, and ICD-10-CM/PCS code sets for hospital claims validation
Familiarity with revenue codes and UB-04 line-level billing structures
Working knowledge of bundling/unbundling rules and NCCI edits
Exposure to DRG grouper logic and case-mix reimbursement principles
Why You’ll Love Working with Us:
🩺DAY 1 HMO Coverage + 1 Free Dependent (Medical & Dental)
💻 Equipment Provided – Everything you need to succeed
🏠 Potent

Employment type
Full-Time

Work arrangement
No