Pharmacist/ Nurse

Job Title: Medical Claims Processor

Minimum requirements: Applicants must be willing to work and relocate to Clark, Pampanga. With Bachelors Degree in Nursing or Midwifery or Pharmacist. Registered Nurse/Midwife/Dental Nurse/PharmacistMinimum of 2 years hospital experience as Staff Midwife, Staff Nurse or Dental Nurse or Pharmacist

Key Responsibilities and Accountabilities

The job holder’s primary task will be to process e-claims received from external medical service providers. This involves: Accurate claims adjudication as per policy terms and conditions. Accurate claims adjudication as per agreed business SOP and within agreed SLA’s. Review and evaluation of medical costs and service line items. Review and evaluation of medical codes, supporting documents and observations todetermine medical appropriateness. Correct escalation of claims as per agreed SOP.Batch reconciliation and closing. The job holder will also be responsible for supporting the team leader with the following tasks, as required: Consolidating claims findings for feedback to EGHQ.Claims reporting and utilisation trend analysis. Adherence to agreed SOP and claims SLA’s. New joiner support and buddy training.