Medical Claims Processor – Nursing Background

About the role

This position is focused on processing electronic medical claims received from external service providers. It is designed for a qualified nurse or midwife who can apply clinical knowledge to evaluate claim validity and ensure compliance with policy guidelines.

Key responsibilities

• Accurately adjudicate claims according to policy terms, business SOPs, and agreed SLA’s.
• Review medical costs, service line items, and supporting documentation to determine appropriateness.
• Evaluate medical codes and observations for compliance.
• Escalate claims correctly following SOPs.
• Perform batch reconciliation and closing activities.
• Support team leader with claim findings consolidation, reporting, and utilization trend analysis.
• Assist with new joiner onboarding and buddy training.

Required profile

• Bachelor’s degree in Nursing or Midwifery.
• Registered Nurse, Midwife, or Dental Nurse.
• Minimum of 2 years hospital experience as Staff Nurse, Staff Midwife, or Dental Nurse.
• Filipino citizenship or relevant residence status.
• Willingness to relocate to Clark, Pampanga.

Required skills

• No specific technical skills listed; strong clinical knowledge and attention to detail are essential.