Hospital Claims Specialist - Potential WFH after Training

About the role

We are seeking an experienced Hospital Claims Specialist to join our Makati team. The role focuses on US healthcare facility claims adjudication, with an onsite start and the possibility of remote work after six months based on performance.

Key responsibilities

• Review and adjudicate inpatient, outpatient, emergency, ancillary, Home Health and SNF claims according to benefit plans and policies.
• Validate eligibility, cost‑share, provider affiliation, coding, service dates, authorizations and supporting documentation.
• Make accurate determinations to pay, deny, adjust, pend or contest claims with proper rationale.
• Identify and address payment‑integrity issues such as duplicate billing and coding discrepancies.
• Research and resolve high‑risk or complex claims using system data, clinical records and authorization details.
• Maintain audit‑ready claim notes and ensure compliance with HIPAA, PHI privacy and internal controls.
• Participate in quality reviews, calibrations and continuous‑improvement initiatives.

Required profile

• Minimum 5 years of hands‑on experience adjudicating US hospital or facility claims in a payer, TPA or managed‑care environment.
• Deep knowledge of institutional billing, reimbursement methodologies and policy‑based claim decision‑making.
• Proven ability to handle complex inpatient and outpatient claims while meeting productivity, quality and compliance standards.
• Urgent availability to start immediately.

Required skills

• Hospital claims adjudication
• HIPAA compliance