Medical Claims Specialist

Medical Claims Specialist

Job Category: Support Group
Job Type: Full Time
Job Location: Cebu City
Job Summary

Make a difference and advance your career with Chong Hua Hospital, the Philippines’ premier healthcare destination!

Chong Hua Hospital is looking to hire an experienced and highly motivated Medical Claims Specialist is mainly responsible for reviewing and analyzing referred charts of discharged patients that may acquire attention and technical in nature. S/he also assesses any denied claims caused by inconsistent data and non-compliance with standard of care. S/he determines whether the denied claims are for appeal, thus, prepares an appeal letter. Moreover, s/he prepares preliminary assessment of patient’s chart pertaining to PhilHealth Insurance Corporation request for a verified letter.  

S/he closely coordinates with the Medical Team for resolution of problematic charts. S/he serves as a medical representative that supports and provides clarification to the Philhealth and Quality Records team in relation to reading charts and verifying claims. One of her/his essential roles is to train the Consultant and Resident Doctors on PhilHealth concepts and rules. S/he is also expected to assist in planning and executing claims improvement initiatives and submit timely and accurate reports of medical claims. 

  • Review medical claims to ensure company reimbursement payments are accurate and reprice claims according to hospital payment schedules and reimbursements. 
  • Negotiate claim settlements and make recommendations for legal action when settlements are deemed non-negotiable. 
  • Reject or accept documentation, determine benefit due, and start the denial or payment process to resolve medical claims. 
  • Maintains updated records and prepares required documentation to support the insurance claims. 
  • Provide excellent customer service when working with customers and hospitals to resolve insurance claim issues, answer questions, and provide solutions to other problems related to medical claims. 
  • Responsible for creating timely and accurate reports on medical claims and appeals. 
  • May be assigned in a project that aims to improve specific areas, working independently or with a cross-functional team. May be tasked to make necessary recommendations on performance of team members or cross-functional team member.  
  • A graduate of any bachelor’s degree,   
  • A minimum of five to seven (5-7) years of relevant work experience in medical field and with background in claims management 
  • Healthcare industry experience is a plus.  
  • Comprehensive knowledge of insurance plans, member eligibility, and medical billing 
  • Strong background in government and commercial payers 
  • Understands medical terminologies 
  • Demonstrated understanding of basic corporate office software, including Microsoft Office 365 applications.  
  • Excellent communication skills. Proficiency in the Visayan dialect and/or Tagalog is required. 

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Employment Applicant Consent Form

In compliance with the Data Privacy Act of 2012 (Republic Act No. 10173), Chong Hua Hospital ensures that your personal data will be handled and processed responsibly and securely.

By ticking the box below, I hereby give my consent to Chong Hua Hospital to collect, use, and process my personal data as part of the recruitment and hiring process.

  1. Personal Data Collection
    I, the undersigned, hereby give my consent to Chong Hua Hospital to collect and process my personal data, including but not limited to my name, contact details, employment history, educational background, and other relevant information
    necessary for the recruitment and hiring process.
  2. Purpose of Data Processing
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  3. Data Storage and Security
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  4. Data Sharing
    I understand that my personal data may be shared within the organization and with third-party service providers, only for the purpose of recruitment and employment-related activities, in accordance with the Data Privacy Act.
  5. Data Subject Rights
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  6. Consent Withdrawal
    I understand that I may withdraw my consent at any time by notifying Chong Hua Hospital in writing, and that withdrawal may affect my eligibility for employment.

I have read and agree to the terms outlined above regarding the collection, use, and processing of my personal data.

CONFIDENTIALITY AGREEMENT

It is the responsibility of all Chong Hua Hospital workforce, including employees, medical staff, house staff, interns, fellows contracted medical staff and volunteers, to preserve and protect the confidential patient, employee and business information.

The Constitution of the Republic of the Philippines (Article III Section 3), Civil Code of the Philippines (Article 19, Article 26), Revised Penal Code of the Philippines on revelation of secrets and the rule on doctor-patient confidentiality govern the release of patient identifiable information by hospitals and other health care providers. All of these laws establish protections to preserve the confidentiality of various medical and personal information and specify that such information may not be disclosed except as authorized by law or the patient or individual.

Confidential Patient Care Information includes: Any individually identifiable information regarding a patient’s medical history, mental, or physical condition or treatment, as well as the patient’s records, test results, conversations, research records and financial information. These may include, but are not limited to:

  • Physical medical and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples;
  • Patient insurance and billing records;
  • Mainframe and department based computerized patient data and alphanumeric radio pager messages;
  • Visual observation of patients receiving medical care or accessing services; and
  • Verbal information provided by or about a patient

I hereby understand and acknowledge that:

  1. I shall respect and maintain the confidentiality of all patient laboratory results, care records and any other information generated in connection with individual patient care, risk management and/or peer review activities;
  2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and other confidential information relating to Chong Hua Hospital and its affiliates, including business, employment and medical information relating to our patients, members, employees and health care providers.
  3. I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of Chong Hua Hospital only with the express approval of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the conduct of Chong Hua Hospital’s healthcare affairs.
  4. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information.
  5. My obligation to safeguard patient confidentiality continues after my termination of deployment with Chong Hua Hospital.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that Chong Hua Hospital may, as applicable and as it deems appropriate, pursue disciplinary action and/or file the appropriate civil and criminal case against me including the termination of my deployment.

This responsibility of confidentiality shall continue even after the completion of my deployment with Chong Hua Hospital.

I AGREE

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