Hospital Claims Specialist

TL;DR

Hospital Claims Specialist: Adjudicating complex US healthcare facility claims with an accent on institutional billing, reimbursement methodologies, and payment integrity. Focus on analyzing inpatient and outpatient claims, ensuring compliance with HIPAA and regulatory standards, and resolving high-dollar or complex cases.

Location: Must be based in Makati, Philippines. Role is onsite for the first 6 months, with potential for hybrid/work-from-home eligibility thereafter based on performance.

Salary: Up to Php 45,000

Company

hirify.global is a leading provider of back-office support technology and tech-enabled outsourced services for health plans, utilizing their proprietary JetStream workflow platform.

What you will do

• Review and adjudicate inpatient, outpatient, ER, and SNF claims according to benefit plans and policies.
• Validate claim accuracy including member eligibility, provider reimbursement, and code validity.
• Make determinations to pay, deny, adjust, or contest claims with clear rationale.
• Research and resolve pended, high-risk, or high-dollar claims using clinical records and itemized bills.
• Identify payment integrity issues such as duplicate billing or coding discrepancies.
• Maintain audit-ready claim notes and support internal/external quality reviews.

Requirements

• At least 5 years of hands-on experience adjudicating US hospital or facility claims.
• Strong knowledge of institutional billing (UB-04, 837I) and reimbursement methodologies (DRG/APR-DRG).
• Proficiency in CPT, HCPCS, and ICD-10-CM/PCS coding sets.
• Experience with Medicare/Medi-Cal claims processing and coordination of benefits.
• Clear and confident English communication skills for documentation and claim notes.
• Ability to work a 6:00 AM – 2:00 PM (PH Time) shift.

Culture & Benefits

• Day 1 HMO coverage including one free dependent (Medical & Dental).
• Equipment provided for the role.
• Potential for work-from-home setup after the initial 6-month onsite period.
• Opportunity to work in a productivity-driven environment with a mission-critical partner to US health plans.