Claims Examiner – Provider Dispute Processor

About the role

We are looking for an experienced Provider Dispute Claims Processor to join our Claims Adjudication team in Makati. The role focuses on reviewing, researching, and resolving provider disputes while ensuring compliance with Medi‑Cal, commercial insurance, and regulatory guidelines.

Key responsibilities

• Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed claims.
• Utilize EZCap to review claims history, adjudication data, and notes.
• Interpret health‑plan policies, provider contracts, and regulatory requirements, especially for Medi‑Cal and commercial plans.
• Review healthcare claims for accuracy and compliance across multiple specialties.
• Validate eligibility, coverage, CPT/ICD‑10/HCPCS codes, and supporting documentation for primary and secondary Medicare claims.
• Identify discrepancies and determine appropriate claim actions (approve, deny, adjust) per policy guidelines.
• Maintain high accuracy (98%+) in claims adjudication while meeting turnaround time and quality standards.

Required profile

• High school diploma or equivalent; associate or bachelor’s degree is a plus.
• 3–5 years of hands‑on experience in provider dispute resolution, claims processing, or adjudication within a health‑plan, TPA, or similar setting.
• Strong knowledge of CPT, ICD‑10, HCPCS coding and Medicare secondary coverage.
• Familiarity with HIPAA, data privacy, and basic cybersecurity standards.
• Proven ability to analyze data, identify trends, and improve workflows.
• Can start ASAP.

Required skills

• EZCap claims review system
• IDX and Facets adjudication platforms
• CPT coding
• ICD‑10 coding
• HCPCS coding
• Medicare claims processing
• HIPAA compliance
• Data analysis and visualization
• Advanced Microsoft Excel
• Microsoft Office Suite (Word, Outlook)