Claims Examiner

Job description

Provider Dispute Claims Processor | Potential for Remote Work After Training Work Setup: In‑Office Training Required Location: Makati – Valero Schedule: Monday to Friday (Shifting Hours) Position Summary: We are seeking an experienced Provider Dispute Claims Processor this role is responsible for reviewing, researching, and resolving provider disputes in compliance with regulatory guidelines and internal policies. The ideal candidate will have hands-on experience and knowledge of Medi-Cal and Commercial Insurance Claims. This position plays a critical role in maintaining provider satisfaction and ensuring compliance with dispute resolution timelines. Key Duties: Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed claims Utilize EZCap to review claims history, adjudication data, and notes Interpret health plan policies, provider contracts, and regulatory requirements (especially Medi-Cal and commercial plans) Reviewed healthcare claims for accuracy and compliance, ensuring timely resolution across multiple specialties. Evaluated authorization details and validated codes to ensure claim approval and compliance. Detected discrepancies that led to appropriate claim denials or adjustments, reducing erroneous payments. Collaborated with internal quality auditors, resulting in a 15% improvement in claims accuracy within the first year. Process and review healthcare claims across multiple specialties (Anesthesia, ARI, DME, Facility, MSK, Surgery, PAP Supplies, COB, and Lab). Verify eligibility, coverage, CPT codes, and supporting documentation for both Primary and Secondary Medicare claims. Identify discrepancies and determine whether to approve, deny, or adjust claims per policy guidelines and medical necessity. Maintain 98%+ accuracy in claims adjudication while consistently meeting turnaround time (TAT) and quality assurance standards. Required Qualifications: High school diploma or equivalent; associate or bachelor’s degree is a plus. At least 3–5 years of hands-on experience in provider dispute resolution within healthcare, third-party administrator (TPA), or health plan settings, including claims processing and adjudication. Proficient in CPT, ICD-10, and HCPCS coding validation; experienced in handling Medicare claims and secondary coverage. Skilled in claims denials, adjustments, and appeals processes, strong knowledge of authorization and eligibility verification. Familiar with HIPAA, data privacy regulations, and basic cybersecurity standards. Strong background in data analysis and visualization to identify trends, improve workflows, and support decision-making. Claims Adjudication Systems: Experienced with platforms such as IDX and Facets. Tools: Proficient in Microsoft Office Suite (Excel, Outlook, Word), with advanced Excel skills. Can start ASAP. Requirements & Work Arrangement: Can start ASAP. This is an urgent hiring. Work Arrangement: This position is currently offered on a remote work basis after successful completion of training (In-office) . However, please note that this is a performance-based role, and the company reserves the right to require employees to report onsite at any time based on business needs, performance evaluations, operational requirements. Flexibility to transition to an office-based setup when necessary is expected. Additional Benefits: HMO - Medical & Dental (coverage on Day1 plus 1 dependent) Transportation Allowance Internat Allowance Equipment will be provided About Imagenet Imagenet is a technology-forward healthcare operations partner with more than 25 years of experience helping healthcare payers manage critical administrative and operational processes. Founded in 2000 and headquartered in Tampa, Florida, Imagenet supports 150+ health plans through its payer clients. Our teams help improve efficiency, accuracy, visibility, and service across complex healthcare operations, including digital mailroom, claims adjudication, contact center, member communications, and related administrative functions. By combining experienced operational teams, proven processes, and purpose-built workflow technology, Imagenet helps payers keep essential processes moving for the members, providers, and communities they serve. Imagenet operates 10 secure facilities across the U.S. and one secure facility in Manila, Philippines. Joining Imagenet means contributing to work that supports the healthcare operations members and providers rely on every day.