Apply Now: PHRN Large Claim Reviewer – Hospital Experience Needed!

• Review and assess large or complex medical claims to determine coverage eligibility and financial risk.
• Identify and escalate potential fraud, waste, or abuse in large claims.
• Analyze medical records, treatment plans, and clinical documentation to validate the necessity and appropriateness of services rendered.
• Collaborate with medical directors, claims adjusters, and legal teams to make informed decisions on high-value claims.
• Determine claim outcomes (approval, denial, or modification) based on underwriting guidelines and policy terms.
• Identify potential fraud or abuse in large claims and escalate for further investigation if necessary.
• Maintain detailed documentation of underwriting decisions and rationale for audit and compliance purposes.
• Maintain reporting and tracking database for assigned groups
• Ability to meet TAT and productivity goals set by management
• Maintain current knowledge and understanding of HIPAA and PHI regulations
• Takes initiative to identify and resolve issues

Your role is critical in allowing our members, families, facilities and health professionals to have greater confidence in the exceptional care we provide. And for you, an everyday opportunity to do your life’s best work.SM

• A graduate of BS Nursing with active PHRN license
• More than 3 years equivalent work experience in Healthcare insurance or healthcare and/or auditing , underwriting, enrollment or degree in a related field of study
• Strong knowledge in BPO Healthcare insurance industry and products
• Strong analytical, problem solving and critical decision-making skills
• Adept with medical terminologies
• Must be willing to commit for long term employment
• Must be willing to report onsite in Quezon City or Taguig

• Market Total Rewards Package
• Retirement Plan
• Medical Plan (HMO) from Day 1 of employment
• Dental, Medical, and Optical Reimbursements
• Life and Disability Insurance
• Paid Time-Off Benefits
• Sick Leave Conversion
• Tuition Fee Reimbursement
• Employee Assistance Program (EAP)
• Annual Performance Based Merit Increases
• Employee Recognition
• Training and Staff Development
• Employee Referral Program
• Employee Volunteerism Opportunity
• All Mandatory Statutory Benefits

• Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.
• UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.
• We’re a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.
• As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.
• We’re a diverse team with operations across North America, South America, Europe, Asia Pacific and the Middle East. This includes our over 25,000 employees in the Philippines.
• Elevate your career with a leading health care company while improving lives.

Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together