Medical Adjudication Specialist at Hive Health – Pasig, Metro Manila

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.

This is a remote role based in Metro Manila, Philippines, subject to change based on business needs. While most work may be accomplished remotely, you must be able to commute to our office in the Ortigas area at least twice per week, as needed.

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