Hospital Claims Specialist - Potential WFH after Training
Hybrid · Makati City, Metro Manila, Philippines
Job Summary
Hospital Claims Specialist with extensive expertise in US facility claims adjudication (inpatient, outpatient, ER, Home Health, SNF). Responsibilities include reviewing and adjudicating hospital claims according to benefit plans and policies, validating accuracy of member eligibility, provider reimbursement, code validity, dates of service, and documentation; applying correct cost share (deductibles, copays, coinsurance, COB); identifying payment integrity issues and complex denials, investigating high-dollar/pended/complex claims, and escalating with clear findings. Maintain audit-ready claim notes, ensure HIPAA/PHI compliance, participate in quality reviews, and support internal/external audits. Strong knowledge of DRG/APC concepts, Medicare/Medi-Cal processing, authorization/referral requirements, and CPT/HCPCS/ICD-10 coding essential; experience with payer platforms and a detail-oriented, analytical approach required. Potential WFH after a training period; initial onsite with transition to remote eligibility based on performance and business needs.
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.
Apply with one swipe on Sorce. We auto-fill applications and apply on your behalf — no cover letters, no 40-minute forms.
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.