Medical Adjudication Specialist
👋🏻 Hi! We’re HPPI, part of the Hive Health Group
About us
HPPI is an HMO that is part of the Hive Health 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 Contractor, 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.
Responsibilities
As an Medical Adjudication Specialist Contractor, 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