Provider Dispute Claims Processor (Healthcare)

TL;DR

Provider Dispute Claims Processor (Healthcare): Reviewing, researching, and resolving provider disputes in compliance with regulatory guidelines and internal policies with an accent on Medi-Cal and Commercial Insurance Claims. Focus on investigating denied or underpaid claims, validating medical codes, and maintaining high adjudication accuracy.

Location: Makati, Metro Manila. In-office training required, followed by potential remote work. Candidates must be flexible to return onsite at any time based on performance or business needs.

Salary: Up to ₱33,000

Company

A leading provider of back-office support technology and tech-enabled outsourced services for healthcare plans nationwide.

What you will do

• Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed healthcare claims.
• Utilize EZCap to review claims history, adjudication data, and notes.
• Interpret health plan policies, provider contracts, and regulatory requirements, specifically for Medi-Cal and commercial plans.
• Verify eligibility, coverage, and CPT codes for Primary and Secondary Medicare claims.
• Collaborate with internal quality auditors to improve claims accuracy.
• Determine whether to approve, deny, or adjust claims based on policy guidelines and medical necessity.

Requirements

• 3–5 years of experience in provider dispute resolution within healthcare, TPA, or health plan settings.
• Proficiency in CPT, ICD-10, and HCPCS coding validation.
• Hands-on experience with claims adjudication platforms such as IDX and Facets.
• Knowledge of HIPAA and data privacy regulations.
• Advanced skills in Microsoft Excel.
• Must be able to start ASAP and attend final interview and assessment onsite in Makati.

Culture & Benefits

• HMO Medical & Dental coverage from Day 1, including one dependent.
• Transportation and Internet allowances.
• Necessary work equipment provided by the company.