Institutional Claims Specialist

TL;DR

Institutional Claims Specialist: Reviewing and adjudicating US hospital and facility claims with an accent on inpatient/outpatient decision-making, payment integrity, and policy-based determinations. Focus on resolving complex pended and high-risk claims, maintaining audit-ready documentation, and ensuring HIPAA-compliant, quality-focused claim processing.

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

• Review and adjudicate hospital/facility claims (inpatient, outpatient, ER, ancillary, Home Health, SNF) according to benefit plans, policies, and 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 with correct member cost share and coordination of benefits (COB).
• Investigate payment integrity issues (duplicate billing, coding discrepancies, billing errors, policy inconsistencies) and resolve complex pended/high-dollar/high-risk claims.
• Maintain clear, complete, audit-ready claim notes and ensure compliance with HIPAA/PHI privacy, internal controls, and regulatory requirements.
• Participate in quality reviews/calibrations and support internal/external audits with documentation and claim decision explanations.

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 handling 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, including the ability to write concise and defensible claim notes.

Culture & Benefits

• Day 1 HMO coverage with 1 free dependent (medical & dental).
• Equipment provided.
• Onsite for the first 6 months, with potential work-from-home eligibility thereafter based on performance and business needs.