Provider Dispute Claims Processor

TL;DR

Provider Dispute Claims Processor (Healthcare Claims): Reviewing, researching, and resolving provider disputes for denied, underpaid, or incorrectly processed claims with an accent on Medi-Cal and commercial insurance claims adjudication. Focus on CPT/ICD-10/HCPCS validation, authorization/eligibility verification, and maintaining high accuracy while meeting dispute resolution timelines.

Location: Makati – Valero (In-office training required); remote work possible after successful training, with potential onsite reporting required based on business needs and performance.

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

• Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed claims.
• Use EZCap to review claims history, adjudication data, and notes.
• Interpret health plan policies, provider contracts, and regulatory requirements (especially Medi-Cal and commercial plans).
• Process and review healthcare claims across multiple specialties, verifying eligibility, coverage, CPT codes, and supporting documentation.
• Determine whether to approve, deny, or adjust claims based on policy guidelines and medical necessity, including authorization details and validated codes.
• Maintain 98%+ accuracy while meeting turnaround time (TAT) and quality assurance standards.

Requirements

• 3–5 years of hands-on experience in provider dispute resolution in healthcare, TPA, or health plan settings, including claims processing and adjudication.
• Proficiency in CPT, ICD-10, and HCPCS coding validation, with experience handling Medicare claims and secondary coverage.
• Strong knowledge of claims denials, adjustments, and appeals processes, including authorization and eligibility verification.
• Familiarity with HIPAA, data privacy regulations, and basic cybersecurity standards.
• Experience with claims adjudication systems such as IDX and Facets.
• Can start ASAP.

Culture & Benefits

• HMO medical and dental coverage (coverage on Day 1 plus 1 dependent).
• Transportation allowance and internet allowance.
• Equipment provided.
• Remote work possible after successful completion of training, with flexibility to transition back onsite when needed.

Hiring process

• Onboarding and in-office training before transitioning to remote work (performance-based).
• Ongoing performance evaluation may require onsite reporting based on business needs and operational requirements.