Key Responsibilities:

Claims Processing – Timeliness and Accuracy

• Review and process medical claims within the standard processing time.
• Ensure accuracy of approved amounts, encoding, and benefits of coverage in line with policies and member entitlements.

Daily Productivity Management

• Meet or exceed daily claims processing targets while maintaining high standards of accuracy and quality.
• Organize workload to ensure consistent processing volume and timely completion.

Compliance and Quality Assurance

• Ensure all processed claims comply with internal policies, medical necessity guidelines, and benefit limitations.
• Flag and escalate discrepancies, incomplete documents, or non-compliant claims for further review.

Data Entry and System Updates

• Accurately encode claims information into the processing system.
• Update claim statuses and resolution notes as required.

Internal Coordination

• Coordinate with internal department to clarify claim issues, seek approvals, or complete documentation.
• Provide support in resolving inquiries related to processed claims.

Continuous Improvement

• Recommend ideas for workflow improvement to reduce bottlenecks and increase efficiency.
• Participate in trainings and calibration sessions to stay updated with policy changes and system updates.

JOB QUALIFICATIONS:

Educational Attainment

• Bachelor's degree in Nursing, Allied Health, Business Administration, or any related field
• Associate degree holders with relevant experience may also be considered

Relevant Experience

• At least 1-2 years of experience in medical claims processing, health insurance operations, or related administrative/ healthcare roles

Areas of Experience

• Medical claims review and processing
• Health insurance or HMO operations
• Data entry and documentation
• Coordination with customers or internal stakeholders

Knowledge

• Basic understanding of medical terms, procedures, and diagnosis codes
• Knowledge of health insurance policies, benefits and claims guidelines
• Familiarity with medical necessity standards and benefit limits
• Proficiency in claims processing system and MS Office applications

Skills

• Strong analytical and decision- making skills
• High attention to detail and accuracy
• Good time management or organization skills
• Clear written and verbal communication
• Fast and accurate data entry skills
• Ability to stay focus during repetitive tasks

Competencies

• Commitment to compliance and quality
• Productivity and results- driven mindset
• Problem- solving and critical thinking
• Integrity and confidentiality
• Teamwork and collaboration
• Adaptability to changing processes

Licensure

• Not Required
• Nursing or medical-related licensure/certification is an advantage

Other Requirements

• Willing to work onsite and on shifting schedules
• Comfortable working with quotas, deadlines, and a fast-paced environment
• Open to training and continuous learning

Job Type: Full-time

Work Location: In person