Senior Claims Examiner (Hospital Claims)

TL;DR

Senior Claims Examiner (US Healthcare): Reviewing and adjudicating complex hospital and facility claims with an accent on institutional billing, reimbursement methodologies, and policy-based decision-making. Focus on resolving high-dollar discrepancies, validating code accuracy, and ensuring HIPAA compliance.

Location: Makati, Philippines. Onsite for the first 5 months, with potential work-from-home eligibility thereafter based on performance.

Salary: Up to 32,000 PHP

Company

hirify.global is a leading provider of back-office support technology and tech-enabled outsourced services for healthcare plans across the United States.

What you will do

• Adjudicate inpatient, outpatient, ER, Home Health, and SNF claims according to benefit plans and policies.
• Validate claim accuracy, including member eligibility, provider affiliation, cost shares, and code validity.
• Research and resolve pended, high-dollar, or high-risk complex hospital claims.
• Identify payment integrity issues such as duplicate billing, coding discrepancies, and policy inconsistencies.
• Maintain audit-ready claim notes and ensure strict adherence to HIPAA and PHI privacy standards.
• Participate in quality reviews and calibrations to reduce errors and improve accuracy.

Requirements

• At least 5 years of experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting.
• Strong knowledge of institutional billing, specifically UB-04 and 837I claim formats.
• Proficiency in DRG / APR-DRG reimbursement and Medicare/Medi-Cal claims processing.
• Understanding of CPT, HCPCS, and ICD-10-CM/PCS code sets and NCCI edits.
• Clear and confident English communication skills for writing concise and defensible claim notes.
• Ability to work the morning shift (6:00 AM – 2:00 PM PH Time).

Nice to have

• Experience supporting Commercial, Medicare Advantage, or Medicaid plans.
• Familiarity with appeals, reconsiderations, or provider dispute resolution.
• Knowledge of APC concepts and medical necessity indicators.
• Experience in a productivity-driven BPO or shared services environment.

Culture & Benefits

• Day 1 HMO coverage including one free dependent (Medical & Dental).
• Full equipment provided for the role.
• Potential transition to a WFH setup based on performance and business needs.