Job Description

1. Ensures timely and accurate adjudication of claims from medical service providers within the authority limits. The task involves:
   1.1 Accurate claims adjudication as per medical guidelines and policies.
   1.2 Accurate claims adjudication as per agreed business Standard Operation
   Procedures within the agreed SLAs.
   1.3 Escalation of claims as per agreed SOP.
   1.4 Review and escalation of medical codes, supporting documents and observations to determine medical appropriateness.
2. Researches and determines medical related claims.
3. Maintains records, files and documentation as appropriate.
4. Adjudicates provides an early payment discount and rebates from accredited hospital and
   ensures non forfeiture of discounts.
5. Processes claims within the set SLAs.
6. Approves claims up to Php4,000.00.
7. Monitors and handles stale claims according to IHC guidelines.
8. Corrects adjudication / entry of audited claims to address audit findings.
9. Prepares AR billing letters to the Members/Company for the non-coverable charges.
10. Sends back claims with incomplete documents to the healthcare providers.
11. Issues Utilization Certificates to the Members/s (if necessary).
12. Reverses all invalid ARs.
13. Prepares Service Request to IST and memo to accounting for some changes in payee name.
14. Assists in telephone inquiries of accredited providers and members.
15. Meet daily quota requirements.
16. Meets 100% productivity / efficiency.
17. Performs other duties assigned by the immediate superior from time to time.