Claim resolution specialist

Claims Resolution Specialist

Site: QC (Onsite) & Pasig (Temporary WFH)

Compensation Package:

₱30,000 Basic Salary (20%ND)

₱1,500 Meal Allowance

₱1,000 Rice Allowance (after 90 days)

₱5,000 Onsite Allowance

Qualifications:

At least 1 year of BPO Healthcare experience processing UB04 & CMS1500

Experience in end-to-end claims processing for Provider/Hospital accounts

Can start on April 6, 2026

JD:

 Appeal Submission and Resolution: Prepare and submit well-documented and persuasive appeals for denied claims, leveraging payer guidelines, contracts, fee schedules, and medical records to resolve issues and trigger payments.

 Escalation Management: Address claims escalated by Claim Status Specialists, resolving complex denial scenarios such as coding disputes, medical necessity issues, or payer policy conflicts.

 Underpayment Resolution: Investigate and address discrepancies between expected and actual payments, taking corrective action to resolve underpayments.

 Final Determination: Evaluate claims to determine if they are resolved or require further action, such as additional appeals, escalation, or account closure based on client requirements.

 Account Closure: Review and close accounts when collection efforts have been exhausted, ensuring proper documentation and compliance with client guidelines.

 Account Review Feedback: Identify incorrectly resolved claims and return them to the appropriate team for review, correction, or training, contributing to process improvements.

 Collaboration: Utilize documentation provided by Document Retrieval Specialists and Claim Status Specialists to perform resolution activities efficiently