Deskripsi Pekerjaan
Are you an experienced insurance professional with a passion for operational excellence? Medicare Plus is seeking a dynamic and detail-oriented Claims Manager to lead our claims department in Ortigas, Metro Manila. In this pivotal role, you will be the backbone of our claims adjudication process, ensuring that our members receive seamless support and that our provider network maintains high standards of service.
As the Claims Manager, you will oversee the end-to-end lifecycle of insurance claims, from initial submission to final adjudication and payment. You will foster strong relationships with healthcare providers, mitigate risks, and implement strategies to increase efficiency in our claims processing workflows. If you are a natural leader who thrives in a fast-paced environment and possesses a deep understanding of the Philippine healthcare insurance landscape, we invite you to join our growing team.
Tanggung Jawab
- Lead, mentor, and supervise the claims department staff to ensure high productivity and quality output.
- Oversee the accurate and timely adjudication of medical claims according to company policies and health plan guidelines.
- Manage and cultivate strong working relationships with partner healthcare providers and facilities.
- Implement and monitor KPIs to reduce claims processing turnaround times and error rates.
- Resolve complex claim disputes and appeals, acting as the final point of escalation.
- Ensure full compliance with industry regulations, data privacy acts (DPA), and internal audit standards.
- Collaborate with the finance team to ensure accurate payment scheduling and financial reporting.
Kualifikasi
- Bachelor’s degree in Nursing, Health Administration, Business Management, or a related field.
- Minimum of 5 years of experience in medical claims processing, preferably within an HMO or health insurance setting.
- At least 2 years in a supervisory or management role overseeing a team.
- Strong knowledge of medical terminology, ICD-10 coding, and PHIC (PhilHealth) guidelines.
- Proficiency in claims management software and MS Office Suite (advanced Excel skills preferred).
- Excellent communication, negotiation, and conflict resolution skills.
- Strong analytical mindset with the ability to identify trends and operational bottlenecks.