Facility Claims Specialist - Potential WFH after Training
Hybrid · Makati City, Metro Manila, Philippines
Job Summary
Facility Claims Specialist responsible for reviewing and adjudicating hospital and facility claims (inpatient, outpatient, emergency room, ancillary, Home Health, SNF) in a US healthcare payer/TPA/managed care setting. Responsibilities include validating eligibility and cost share, verifying provider affiliation and reimbursement, ensuring code validity, determining accurate claim outcomes (pay/deny/adjust/pend/contest) with documented rationale, applying COB and benefit deductions, identifying payment integrity issues, investigating high-dollar or complex claims, escalating policy gaps and system issues with recommendations, maintaining audit-ready notes, ensuring HIPAA/PHI compliance, participating in quality improvements, and supporting audits. Requires deep knowledge of institutional billing, DRG/APR-DRG methodologies, Medicare/Medi-Cal processing, and strong analytical/communication skills. Preferred: experience with Commercial/Medicare Advantage/Medicaid, appeals, DRG/APC concepts, and productivity/quality-driven BPO/shared services experience. Technical knowledge includes CPT/HCPCS/ICD-10-CM/PCS, UB-04 line-item billing, bundling/unbundling, NCCI edits, and DRG case-mix concepts. Benefits include HMO coverage Day 1 and potential WFH after training.
Required Qualifications
- At least 5 years of hands-on experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting
- Strong working knowledge of institutional billing, including UB-04 and 837I claim formats
- Proven experience handling inpatient, outpatient, emergency room, Home Health, and SNF claims, including complex cases
- Understanding of DRG/APR-DRG reimbursement methodologies
- Medicare and Medi-Cal claims processing
- Prior authorization and referral requirements
- Eligibility and benefits
- Timely filing rules
- Coordination of benefits
- Overpayment and underpayment identification
- Provider contracts and reimbursement terms
- Payer policies
- Benefit summaries
- Claims processing guidelines
- CPT, HCPCS, ICD-10-CM/PCS codes
- UB-04 line-level billing
- DRG grouping logic
- Readmission logic
- Medical necessity indicators
- Post-payment review
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