Facility Claims Specialist (US Healthcare Claims Adjudication)

TL;DR

Facility Claims Specialist (US Healthcare Claims Adjudication): Review and adjudicate complex US hospital and facility claims with an accent on institutional billing accuracy, payment integrity, and policy-based determinations. Focus on resolving pended/high-risk claims through analysis of claim history, clinical records, and authorization details while maintaining HIPAA-compliant, audit-ready documentation.

Location: Makati

Salary: up to Php 45,000

Company

hirify.global provides back-office support technology and tech-enabled outsourced services for healthcare plans, including claims processing and adjudication.

What you will do

• Adjudicate inpatient, outpatient, ER, ancillary, Home Health, and SNF hospital/facility claims using benefit plans, policies, and standard procedures.
• Validate claim accuracy and completeness (eligibility/cost share, provider affiliation, code validity, dates of service, authorization/referrals, supporting documentation).
• Determine pay/deny/adjust/pend/contest decisions and apply deductibles, copayments, coinsurance, benefit limits, and coordination of benefits (COB).
• Investigate and resolve pended, high-dollar, high-risk, or complex claims using system data, claim history, itemized bills, clinical records, and authorization details.
• Maintain audit-ready claim notes, ensure HIPAA/PHI privacy and compliance, and support quality reviews and internal/external audits.

Requirements

• At least 5 years of hands-on experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting.
• Strong institutional billing knowledge, including UB-04 and 837I claim formats.
• Experience with inpatient, outpatient, ER, Home Health, and SNF claims, including complex cases.
• Solid understanding of DRG/APR-DRG reimbursement, Medicare and Medi-Cal claims processing, prior authorization/referrals, eligibility/benefits, timely filing rules, COB, and overpayment/underpayment identification.
• Ability to independently interpret provider contracts/reimbursement terms, payer policies, benefit summaries, and claims processing guidelines.
• Clear and confident English communication skills for concise, defensible claim notes.

Nice to have

• Experience supporting Commercial, Medicare Advantage, or Medicaid plans.
• Familiarity with appeals, reconsiderations, or provider dispute resolution.
• Working knowledge of DRG/APC concepts, readmission logic, medical necessity indicators, and post-payment review.
• Experience in a productivity- and quality-driven BPO/shared services environment.

Culture & Benefits

• Onsite for the first 6 months, with potential work-from-home eligibility thereafter based on performance and business needs.
• Day 1 HMO coverage with 1 free dependent (medical and dental).
• Equipment provided.
• Shift: 6:00 AM – 2:00 PM (PH Time).