Claims Expert

Responsibilities:

• - Review and validate diagnosis and medication coding for infusion services, with a focus on payer-specific requirements and restrictions, serving as the primary resource for complex or non-standard cases.
• - Analyze payer medical policies and CMS guidelines to determine coverage eligibility and medical necessity, providing expert interpretation in ambiguous or evolving policy situations.
• - Ensure clinical documentation is accurately aligned with billing and coding requirements before services are rendered.
• - Oversee the completion and validation of Advance Beneficiary Notices (ABNs), ensuring appropriate modifier usage and system documentation.
• - Apply advanced knowledge of Medicare regulations and FDA-approved indications to support coding decisions, independently addressing exceptions, denials, and off-label coverage scenarios.
• - Partner with infusion intake, billing, and clinical teams to resolve coding inconsistencies and recommend corrective documentation practices.
• - Investigate, prioritize, and resolve complex reimbursement and compliance issues, escalating concerns only when regulatory or systemic risks are identified.
• - Maintain comprehensive and audit-ready documentation to support coding determinations, compliance reviews, and post-payment audits.
• - Ensure adherence to regulatory requirements, payer guidelines, and organizational billing policies.
• - Contribute to process improvement initiatives aimed at enhancing coding accuracy, maximizing reimbursement, and standardizing intake workflows.
• - Train and onboard new Claims Coordinators on systems, procedures, and industry best practices, while providing ongoing mentorship and operational support to team members.

Qualifications:

- Bachelor's Degree: Specialty/Major: Nursing, Health Information Management, Medical Coding, or related field

- Active Certified Professional Coder (CPC) - American Academy of Professional Coders or American Health Information Management
Association (AHIMA); Active Philippine Registered Nurse (PHRN)
- 3+ years of experience in medical coding, healthcare billing, or revenue cycle
- Trained in coding systems, payer policies, and internal workflows

Location: BGC, Taguig

Work set-up: Full onsite

Schedule: Shifting