Medical Claims Examiner

TL;DR

Medical Claims Examiner: Processing and adjudicating medical claims for US healthcare plans with an accent on accuracy, coding compliance, and reimbursement methodology. Focus on verifying patient eligibility, resolving claim discrepancies, and ensuring adherence to turnaround times in a performance-based environment.

Location: Must be based in Makati, Philippines. The role requires in-office training with the potential for remote work thereafter, subject to performance and business needs.

Company

hirify.global is a premier healthcare technology company providing back-office support, claims processing, and document management solutions to over 70 health plans nationwide.

What you will do

• Review and adjudicate professional and institutional medical claims.
• Verify patient eligibility, provider credentialing, and coverage details.
• Ensure accurate coding and application of reimbursement methodologies.
• Communicate with internal stakeholders to resolve claim discrepancies.
• Maintain detailed records of processing activities and ensure compliance with turnaround times.
• Identify and escalate complex or unusual claims for further investigation.

Requirements

• 2+ years of experience in US healthcare claims processing or adjudication.
• Understanding of ICD-9 and ICD-10 coding.
• Ability to perform basic to intermediate mathematical computations.
• Proficiency in MS Office and strong attention to detail.
• Must be able to start ASAP and commit to in-office training in Makati.
• Strong written and verbal communication skills.

Nice to have

• Prior knowledge of medical terminology.
• Experience with various lines of business such as Medicare, PPO, or Medi-Cal.

Culture & Benefits

• Comprehensive HMO coverage for employee and one dependent starting on Day 1.
• Transportation allowance provided.
• Necessary equipment for the role is supplied by the company.
• Professional development and ongoing training opportunities.