Institutional Claims Specialist - Potential WFH after Training

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    "departmentLabel": "Claims Adjudication",
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    "description": "<p><span style=\"color: rgb(0, 0, 0); font-size: 18pt; font-weight: bold\">Institutional Claims Specialist - Potential WFH after Training</span></p>\n<p><br></p>\n<p><span style=\"font-weight: bold\">Location:</span> Makati<br><span style=\"font-weight: bold\">Employment Type:</span> Full-time<br><span style=\"font-weight: bold\">Shift:</span> 6:00 AM – 2:00 PM (PH Time)<br><span style=\"font-weight: bold\">Work Setup:</span> Onsite for the first 6 months, with potential work-from-home eligibility thereafter based on performance and business needs</p>\n<p><span style=\"font-weight: bold\">Pay Rate: up to Php 45,000</span></p>\n<p><br></p>\n<p><span style=\"color: rgb(186, 55, 42); font-weight: bold\">THIS IS AN URGENT HIRING!  We will prioritize those who can commit and start ASAP.</span></p>\n<p><br></p>\n<p><span style=\"font-weight: bold\">About the Role</span></p>\n<p><br></p>\n<p>We are looking for a highly experienced <span style=\"font-weight: bold\">Institutional Claims Specialist </span>with strong hands-on expertise in US healthcare facility claims adjudication. This role is ideal for a candidate who has worked in a payer, TPA, or managed care environment and can independently review, analyze, and resolve complex hospital claims with accuracy, consistency, and sound judgment.</p>\n<p><br></p>\n<p>The ideal candidate has deep knowledge of institutional billing, hospital reimbursement methodologies, and policy-based claim decision-making, and is confident handling complex inpatient and outpatient claims while meeting productivity, quality, and compliance standards.</p>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Key Responsibilities:</span></span></p>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Hospital Claims Adjudication</span></span></p>\n<ul>\n<li>Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, ancillary, Home Health, and SNF claims, in accordance with benefit plans, policies, and standard procedures.</li>\n<li>Validate claim accuracy and completeness, including:\n<ul>\n<li>member eligibility and cost share</li>\n<li>provider affiliation and reimbursement</li>\n<li>code validity</li>\n<li>dates of service</li>\n<li>authorization and referral requirements</li>\n<li>supporting documentation</li>\n</ul>\n</li>\n<li>Make accurate claim determinations to pay, deny, adjust, pend, or contest claims, supported by proper rationale and documentation.</li>\n<li>Apply member cost share correctly, including deductibles, copayments, coinsurance, benefit limits, and coordination of benefits (COB).</li>\n<li>Identify payment integrity issues such as duplicate billing, coding discrepancies, billing errors, and policy inconsistencies.</li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Investigation &amp; Complex Claim Resolution</span></span></p>\n<ul>\n<li>Research and resolve<br>pended, high-dollar, high-risk, or complex hospital claims through analysis of system data, claim history, itemized bills, clinical records, and authorization details.</li>\n<li>Exercise sound judgment in reviewing claims that require deeper investigation and independent decision-making.</li>\n<li>Identify unclear policy interpretation, configuration gaps, and system-related issues, then escalate with clear findings and recommendations.</li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Documentation, Compliance &amp; Quality</span></span></p>\n<ul>\n<li>Maintain clear, complete, and audit-ready claim notes to support all claim decisions.</li>\n<li>Ensure adherence to HIPAA, PHI privacy standards, internal controls, and regulatory requirements.</li>\n<li>Participate in quality reviews, calibrations, and continuous improvement initiatives to reduce errors and improve accuracy.</li>\n<li>Support internal and external audits by providing documentation and explanation of claim decisions when needed.</li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Required Qualifications</span></span></p>\n<ul>\n<li>At least <span style=\"font-weight: bold\">5 years of hands-on experience adjudicating US hospital or facility claims</span> in a <span style=\"font-weight: bold\">payer, TPA, or managed care setting</span>.</li>\n<li>Strong working knowledge of <span style=\"font-weight: bold\">institutional billing</span>, including <span style=\"font-weight: bold\">UB-04 and 837I claim formats</span>.</li>\n<li>Proven experience handling <span style=\"font-weight: bold\">inpatient, outpatient, emergency room, Home Health, and SNF claims</span>, including complex cases.</li>\n<li>Solid understanding of:<br>\n<ul>\n<li>DRG / APR-DRG reimbursement methodologies</li>\n<li>Medicare and Medi-Cal claims processing</li>\n<li>prior authorization and referral requirements</li>\n<li>eligibility and benefits</li>\n<li>timely filing rules</li>\n<li>coordination of benefits</li>\n<li>overpayment and underpayment identification</li>\n</ul>\n</li>\n<li>Ability to independently interpret:\n<ul>\n<li>provider contracts and reimbursement terms</li>\n<li>payer policies</li>\n<li>benefit summaries</li>\n<li>claims processing guidelines</li>\n</ul>\n</li>\n<li>Strong analytical skills, attention to detail, and sound judgment.</li>\n<li>Experience handling complex denials, pricing logic, payment integrity review, and high-dollar institutional claims is highly preferred.</li>\n<li>Familiarity with payer platforms and claims adjudication systems.</li>\n<li>Clear and confident English communication skills, including the ability to write concise and defensible claim notes.</li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Preferred Qualifications</span></span></p>\n<ul>\n<li>Experience supporting <span style=\"font-weight: bold\">Commercial, Medicare Advantage, or Medicaid</span> plans.</li>\n<li>Familiarity with <span style=\"font-weight: bold\">appeals, reconsiderations, or provider dispute resolution</span>.</li>\n<li>Working knowledge of <span style=\"font-weight: bold\">DRG and APC concepts, readmission logic, medical necessity indicators, and post-payment review</span>.</li>\n<li>Experience in a <span style=\"font-weight: bold\">productivity- and quality-driven BPO or shared services environment</span>.</li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Technical Knowledge Required</span></span></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Claims &amp; Coding Knowledge</span></span></p>\n<ul>\n<li>Strong understanding of <span style=\"font-weight: bold\">CPT, HCPCS, and ICD-10-CM/PCS</span> code sets for hospital claims validation</li>\n<li>Familiarity with <span style=\"font-weight: bold\">revenue codes</span> and <span style=\"font-weight: bold\">UB-04 line-level billing structures</span></li>\n<li>Working knowledge of <span style=\"font-weight: bold\">bundling/unbundling rules</span> and <span style=\"font-weight: bold\">NCCI edits</span></li>\n<li>Exposure to <span style=\"font-weight: bold\">DRG grouper logic</span> and <span style=\"font-weight: bold\">case-mix reimbursement principles</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 12pt\"><span style=\"font-weight: bold\">Why You’ll Love Working with Us:</span></span><span style=\"font-size: 14pt\"><br></span></p>\n<ul>\n<li><span style=\"font-weight: bold\">🩺</span><span style=\"font-weight: bold\">DAY 1 HMO Coverage + 1 Free Dependent </span><span style=\"font-weight: bold\">(Medical &amp; Dental)</span></li>\n<li><span>💻 </span><span style=\"font-weight: bold\">Equipment Provided</span><span> </span>– Everything you need to succeed</li>\n<li>🏠<span> </span><span style=\"font-weight: bold\">Potential WFH set-up based on performance</span></li>\n</ul>\n<p><br></p>\n<p><br></p>\n<p><span style=\"font-weight: bold\">COMPANY OVERVIEW:</span></p>\n<p><span>Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers. </span></p>\n<p><br></p>\n<p><span>The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans’ members and providers.  The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually.  The company has also developed an innovative workflow technology platform, JetStream<em>TM</em>, to help with traceability, governance and automation of claims operations for its clients.</span></p>\n<p><br></p>\n<p><span>Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines</span>.</p>",
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