Hospital Claims Team Leader - Potential WFH after Training
Location: Makati
Employment Type: Full-time
Shift: Tuesday to Saturday, 6:00 AM β 2:00 PM (PH Time)
Work Setup: Onsite for the first 6 months, with potential work-from-home eligibility thereafter based on performance and business needs
About the Role
We are looking for a highly experienced Hospital Claims Team Leader with strong hands-on expertise in US healthcare facility claims adjudication. This role is ideal for a candidate who has worked in a payer, TPA, or managed care environment and can independently review, analyze, and resolve complex hospital claims with accuracy, consistency, and sound judgment.
The ideal candidate has deep knowledge of institutional billing, hospital reimbursement methodologies, and policy-based claim decision-making, and is confident handling complex inpatient and outpatient claims while managing a team of 10-12 Hospital Claim Examiners
Key Responsibilities:
- Accountable for daily claims operations to meet accuracy, productivity and quality goals.
- Conduct regular weekly, monthly, and quality reviews, error trend analysis, and corrective action planning.
- Manage team performance through coaching, performance monitoring, and issue resolution.
- Develop and mentor examiners, identifying future leads and SMEs.
- Partner with training and QA teams to strengthen onboarding, refresher training, accuracy, and consistency.
- Handle client or stakeholder communication, escalations, and operational updates in a timely and professional manner.
- Provide regular business updates on team performance, quality, service levels, and improvement actions.
- Drive continuous improvement initiatives to reduce errors, delays, and rework.
- Ensure adherence to operational processes, controls, and compliance requirements.
- Collaborate with cross-functional teams such as QA, training, workforce management, HR, and client services to support execution.
- Attend and successfully complete all examiner training, certification, and nesting requirements alongside new hire examiners to develop a thorough understanding of client policies, workflows, systems, and claim adjudication processes.
- This is a working Team Leader role. The selected candidate will be expected to manage a team while also maintaining hands-on claims adjudication responsibilities including processing claims, auditing claims, and serving as the primary hospital claims subject matter expert.
- Ability to independently adjudicate complex hospital claims and serve as a subject matter expert for the hospital claims adjudication team.
- Maintain proficiency in hospital claims adjudication by processing claims and handling complex claim scenarios
- Serve as the escalation point for complex claim reviews, payment determinations, and policy interpretation.
- Perform quality reviews and independently adjudicate high-risk, high-dollar, or complex facility claims.
Required Qualifications
- At least 4 years of hands-on experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting.
- 2+ years of team leadership experience; managing a team of 10-12 Claim Examiners who are involved in adjudicating US hospital or facility claims in a payer, TPA, or managed care setting.
- Strong working knowledge of institutional billing, including UB-04 and 837I claim formats.
- Proven experience handling inpatient, outpatient, emergency room, Home Health, and SNF claims, including complex cases.
- Familiarity with payer platforms and claims adjudication systems.
- Clear and confident English communication skills, including the ability to write concise and defensible claim notes.
Preferred Qualifications
- Experience supporting Commercial, Medicare Advantage, or Medicaid plans.
- Familiarity with appeals, reconsiderations, or provider dispute resolution.
- Working knowledge of DRG and APC concepts, readmission logic, medical necessity indicators, and post-payment review.
- Experience in a productivity- and quality-driven BPO or shared services environment.
Technical Knowledge Required
Claims & Coding Knowledge
- Strong understanding of CPT, HCPCS, and ICD-10-CM/PCS code sets for hospital claims validation
- Familiarity with revenue codes and UB-04 line-level billing structures
- Working knowledge of bundling/unbundling rules and NCCI edits
- Exposure to DRG grouper logic and case-mix reimbursement principles
- Facility/Hospital Claims adjudication, ICD-10/CPT/HCPCS/REV coding review, Home Health claims, Skilled Nursing Facility (SNF) claims, Dialysis/ESRD claims, Inpatient and Outpatient hospital claims, Commercial, Medicare and Medicaid regulations, pricing models including but not limited to DRG, OPPS, APC, Case Rates, PDPM, provider billing guidelines, claims investigation, appeals processing, HIPAA compliance, authorizations.
Why Youβll Love Working with Us:
- π©ΊDAY 1 HMO Coverage + 1 Free Dependent (Medical & Dental)
- π» Equipment Provided β Everything you need to succeed
- π Potential WFH set-up based on performance
COMPANY OVERVIEW
Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plansβ members and providers.
The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plansβ members and providers. The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually. The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance and automation of claims operations for its clients.
Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.
