Clinical Support Specialist Medical Claims & Adjudication

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.