Hospital Claims Specialist - Potential WFH after Training

ImageNetLLC

6d • Onsite

About The Position

Imagenet is seeking a highly experienced Hospital Claims Specialist to independently review, analyze, and resolve complex US healthcare facility claims. The role focuses on accurate, consistent, policy-based adjudication of inpatient and outpatient claims while meeting productivity, quality, and compliance standards. The position is onsite in Makati for the first six months, with potential work-from-home eligibility afterward based on performance and business needs. The employer is prioritizing applicants who can commit and start as soon as possible.

The specialist will adjudicate hospital and facility claims across inpatient, outpatient, emergency room, ancillary, Home Health, and SNF services. Work includes validating eligibility, cost share, provider affiliation, reimbursement codes, dates of service, authorization and referral requirements, and supporting documentation; making and documenting claim decisions; applying benefits and coordination of benefits; and identifying payment-integrity issues. The role also investigates complex, pended, high-dollar, and high-risk claims, escalates policy or system issues, maintains audit-ready notes, follows privacy and regulatory requirements, and participates in quality, audit, and process-improvement activities.

Imagenet is a healthcare operations partner founded in 2000 and headquartered in Tampa, Florida. It supports more than 150 health plans through payer clients and operates 10 secure facilities in the United States and one in Manila, Philippines. Its services include digital mailroom, claims adjudication, contact center, member communications, and related administrative functions.

Requirements

• 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.
• Experience handling inpatient, outpatient, emergency room, Home Health, and SNF claims, including complex cases.
• Understanding of DRG and APR-DRG reimbursement methodologies.
• Knowledge of Medicare and Medi-Cal claims processing, prior authorization and referral requirements, eligibility and benefits, timely filing rules, coordination of benefits, and overpayment and underpayment identification.
• Ability to independently interpret provider contracts and reimbursement terms, payer policies, benefit summaries, and claims processing guidelines.
• Strong analytical skills, attention to detail, and sound judgment.
• Clear and confident English communication skills, including the ability to write concise, defensible claim notes.
• Strong understanding of CPT, HCPCS, and ICD-10-CM/PCS code sets for hospital claims validation.
• Familiarity with revenue codes and UB-04 line-level billing structures.
• Working knowledge of bundling and unbundling rules and NCCI edits.

Nice To Haves

• Experience handling complex denials, pricing logic, payment-integrity reviews, and high-dollar institutional claims.
• Familiarity with payer platforms and claims adjudication systems.
• Experience supporting Commercial, Medicare Advantage, or Medicaid plans.
• Familiarity with appeals, reconsiderations, or provider dispute resolution.
• Working knowledge of DRG and APC concepts, readmission logic, medical necessity indicators, and post-payment review.
• Experience in a productivity- and quality-driven BPO or shared-services environment.
• Exposure to DRG grouper logic and case-mix reimbursement principles.

Responsibilities

• Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, ancillary, Home Health, and SNF claims, according to benefit plans, policies, and procedures.
• Validate claim accuracy and completeness, including member eligibility and cost share, provider affiliation and reimbursement codes, dates of service, authorization and referral requirements, and supporting documentation.
• Determine whether claims should be paid, denied, adjusted, pended, or contested, and document appropriate rationale.
• Apply deductibles, copayments, coinsurance, benefit limits, and coordination of benefits correctly.
• Identify duplicate billing, coding discrepancies, billing errors, policy inconsistencies, and other payment-integrity issues.
• Research and resolve pended, high-dollar, high-risk, and complex claims using system data, claim history, itemized bills, clinical records, and authorization details.
• Exercise independent judgment on claims requiring deeper investigation and decision-making.
• Identify and escalate unclear policy interpretation, configuration gaps, and system-related issues with findings and recommendations.
• Maintain clear, complete, audit-ready claim notes supporting claim decisions.
• Follow HIPAA, PHI privacy standards, internal controls, and regulatory requirements.
• Participate in quality reviews, calibrations, and continuous-improvement initiatives.
• Support internal and external audits by providing documentation and explanations of claim decisions.

Benefits

• Day 1 HMO coverage with one free dependent, including medical and dental coverage.
• Equipment provided.
• Potential work-from-home setup based on performance and business needs.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed