Operations Coordinator (Healthcare)

US Operations Coordinator (Healthcare)

Duties/Responsibilities:

Premium Billing, Claims, & Escrow Administration:

• Oversee premium billing processes and related teams that are responsible for invoicing, reconciliation, and generating weekly and monthly refund and chargeback reports.
• Support day-to-day administrative functions such as compliance documentation, account maintenance, and audit prep.
• Work with various client vendor in fulfillment of the company’s TPA responsibilities (E123, PayByCliq, Elevate, NMI, Rectangle Health, QEnroll, etc.).
• Ensure timely processing of regular payments to various TPA payees (i.e. commissions and premium) .
• Conduct regular claims and escrow reconciliation, coordinating with the Operations/Claims Department and Finance Manager to resolve any discrepancies.
• Maintain a systematic record of claims and escrow files, ensuring compliance with internal and external reporting requirements.
• Work with various team members to ensure all SLA and KPIs are met.

Client Management:

• Account management for US-based clients.
• Work with business development team as need to ensure client satisfaction targets are met

Claims Re-pricing and Management

• Compile, verify, interpret, analyze and summary of claim data and preparation of client payment report.
• Investigating potentially fraudulent claims.
• Identify and resolve claim related inquiries and issues.
• Ensure team organizes scanned or electronically submitted claims and they are split, renamed and consolidated into the designated batch in the document repository.
• Ensure accurately and efficiently encode data in the claim monitoring file.
• Ensure all claims received are processed within the set turnaround time, analyzed, and entered in the claim repricing system.
• Generate and issue EOAC (explanation of allowable benefits) or EOB (Explanation of Benefits) to members and providers.

Adaptation of Responsibilities Based on Business Requirements in Cases of Limited Transactions

In the event of limited or no transactions, the Operations Coordinator may be assigned additional responsibilities to support the team's ongoing needs.

Customer / Member Services

• Oversee customer service team and provide quality customer service as necessary.
• Properly document and update call and complaint logs as well as generate activity reports routinely using the company’s CRM tools
• Ensure team handles inbound and outbound customer service-related calls for members and health care providers.
• Transfer and/or escalate select inquiries to the appropriate person or department as indicated by management.

Provider Network Management

• Maintain and cultivate relationships with the Company’s provider network partners.
• Identify new networks and composition of networks to meet the diverse needs of company’s clients.

Management and Administration

• Coordinate with Human Resources Department concerning new staff recruitment, administration, and employment matters.
• Attend and participate in company, client and provider project and operations meetings.
• Work with compliance team to ensure company is compliant with all State and Federal Regulations and data privacy laws (i.e. HIPAA)

Requirements:

Experience:

• Mid- to senior-level experience in operations, preferably within insurance, healthcare, or TPA environments
• Proven experience handling US accounts, w/ strong understanding of US business practices, client expectations, and regulatory considerations
• Claims processing: 3 years (Preferred)
• US account TPA Insurance: 3 years (Preferred)

Job Type: Full-time

Ability to commute/relocate:

• Makati: Reliably commute or planning to relocate before starting work (Required)

Work Location: In person