Institutional Claims Specialist - Potential WFH after Training
$9,720–$9,720 year
Hybrid · Makati City, Metro Manila, Philippines
Job Summary
Institutional Claims Specialist role focusing on hospital and facility claims adjudication (inpatient, outpatient, ER, SNF, Home Health) with independent analysis, ensuring HIPAA/compliance, and maintaining audit-ready documentation. Requires deep knowledge of institutional billing (UB-04, 837I), DRG/APR-DRG methods, Medicare/Medi-Cal processing, and strong analytical skills to review complex claims, identify errors, and make accurate determinations to pay, deny, adjust, pend, or contest claims. Potential WFH after an initial onsite training period; hybrid work arrangement based on performance and business needs. Strong English communication and documentation abilities are essential.
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
- Familiarity with CPT, HCPCS, and ICD-10-CM/PCS code sets for hospital claims validation
- Experience with DRG/APR-DRG reimbursement methodologies, Medicare and Medi-Cal claims processing, prior authorization and referral requirements, eligibility and benefits, timely filing rules, and COB
- Ability to interpret provider contracts and reimbursement terms, payer policies, benefit summaries, and claims processing guidelines
- Strong analytical skills, attention to detail, and sound judgment
- Experience handling complex denials, pricing logic, payment integrity review, and high-dollar institutional claims is highly preferred
- Familiarity with payer platforms and claims adjudication systems
- Clear and confident English communication skills, including the ability to write concise and defensible claim notes
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