Medical Adjudication Specialist

Job description

Ready to make an impact? At Hive Health http://ourhivehealth.com, we’re on a mission to make healthcare radically more accessible for all—and we need passionate, driven individuals to help us make it happen. If you thrive in a fast-paced, innovative environment and want to work on solutions that truly matter, we’d love to meet you! 👋🏻 HI! WE’RE HPPI, PART OF THE HIVE HEALTH GROUP ABOUT US HPPI https://www.hppi.com.ph/ is an HMO that is part of the Hive Health https://www.ourhivehealth.com/?utm_source=recruiting Group of Companies, which is on a mission to provide the best-in-class health plans for small-medium enterprises (SMEs) in the Philippines. HPPI’s 30+ years of providing care, combined with Hive Health’s innovative tech capabilities, enables the Hive Health Group of Companies to offer comprehensive, hassle-free digital health plans through our all-in-one platform. Together, we are revolutionizing access to quality, affordable healthcare for millions of Filipinos, one SME at a time. About the role As an Medical Adjudication Specialist, you will play a key role in optimizing healthcare operations by meticulously reviewing, analyzing, and validating medical availments and claims, ensuring accuracy, compliance, and timely resolution to support seamless service delivery. As a member of the team, you will work closely with the other functions and innovations in continuously delivering user experience improvements and introducing best-in-class strategies and processes that will help Hive Health provide an unparalleled healthcare experience for Filipinos. This is a hybrid role based in Ortigas, Pasig. Responsibilities As an Medical Adjudication Specialist, your areas of responsibilities include: - Provide clinical guidance to ambiguous, complex outpatient cases to facilitate approvals of medical availments. - Review, adjudicate, and approve cases related to inpatient discharges, ensuring accurate coverage decisions and smooth patient transitions. - Take the lead in providing critical weekend and after-hours support, ensuring urgent cases are managed promptly and healthcare services remain uninterrupted. - Evaluate member utilization by analyzing claims data, categorizing cases by illness, and determining remaining coverage limits to ensure proper benefit allocation. Qualifications - At least 3 years of relevant clinical experience, with familiarity on health coverage policies and a graduate of medical school - Creative, detail-oriented, proactive in problem solving and identifying opportunities - Curious, results-driven, ownership mentality with growth mindset - Excellent verbal and written communications - Collaborative team player with the ability to adapt quickly in a fast-paced environment - Passion for innovation in healthcare Join our team as we revolutionalize healthcare in the Philippines—and beyond! ✨ Day 1 benefits for full-time employees – because we practice what we preach! Enjoy comprehensive healthcare coverage for you and your dependent, and paid time off from the start. 🚀 Grow with us – mentorship, career development, and learning opportunities to help you thrive. 🌍 Global connections – gain insights and support from top minds at Harvard, Stanford, and beyond.