Work Setup: Hybrid

Work Schedule: Regular Schedule

Work Location: Paseo De Roxas, Makati City

Responsibilities:

Clinical Interpretation & Translation

Translate clinical terminology, free-text medical descriptions, and policy language into clear and clinically sound claims adjudication and coding guidance.
Provide guidance on ICD-10, CPT, or applicable local coding standards when documentation is unclear, incomplete, or ambiguous.
Serve as a key clinical resource for questions related to claims assessment, configuration, and adjudication.

Clinical Review & Decision Support

Provide clinical input on claims requiring medical judgment, including medical necessity, appropriateness of care, length of stay, and treatment pathways.
Review pre-authorizations and guarantee-of-payment requests in accordance with applicable processes and guidelines.
Collaborate with senior claims professionals on complex, high-value, or clinically sensitive cases, providing the appropriate clinical perspective.

Clinical Support for Configuration

Support configuration activities by providing clinical interpretation of benefits, exclusions, medical definitions, and policy provisions.
Provide clinical guidance in interpreting medical terminology, definitions, and benefit-related requirements.
Apply knowledge of local clinical practices and healthcare standards to specific cases and configuration decisions, consulting relevant clinical subject matter experts when required.

Fraud, Waste & Abuse

Identify clinical patterns or claim activities that may indicate fraud, waste, or abuse, including potential upcoding, unbundling, unnecessary admissions, or treatments that fall outside established clinical guidelines.
Collaborate with claims, medical, and investigation teams to assess and address potentially inappropriate or suspicious claims activity.

Knowledge Sharing

Coach and support team members on relevant clinical concepts, medical terminology, common treatment pathways, and interpretation of clinical documentation.
Share clinical insights with relevant clinical, product, and operational teams to support process improvements and the enhancement of claims-related platforms and solutions.

Candidate Profile:

Experience & Qualifications

Registered Medical Doctor (MD/MBBS) or Nurse with significant clinical experience. Candidates from other relevant clinical backgrounds, such as Pharmacy or Allied Health, may also be considered.
At least 3 years of experience in health insurance, TPA, hospital case management, medical claims, or a related healthcare environment, with experience applying clinical knowledge to operational or non-clinical decisions.
Familiarity with local healthcare practices, hospital systems, and provider behaviors within the relevant market.
Strong working knowledge of medical coding, including ICD-10, CPT, or applicable local equivalents, and clinical documentation.
Comfortable working in a commercial and operational environment, with the ability to translate clinical judgment into clear and actionable recommendations for operations, product, and business stakeholders.
Strong communication and stakeholder management skills, with the ability to collaborate effectively across clinical, claims, operations, and business teams.
Working proficiency in English.

Clinical Support Specialist Medical Claims & Adjudication