Senior Claims Specialist

Thank you for considering a career at Bon Secours Mercy Health! Scheduled Weekly Hours: 40 Work Shift: 8am to 5pm (Philippines) Flexibility in schedule / Shifting Primary Function/General Purpose of Position The Claims Coordinator, Infusion Intake (Expert) is responsible for advanced review of diagnosis and medication coding prior to infusion administration, including oversight of complex, high ‑ risk, or exception ‑ based cases to ensure accurate billing and reimbursement. This role evaluates payer requirements, regulatory guidelines, and medical necessity criteria while serving as a subject matter expert for nuanced reimbursement determinations that materially impact revenue cycle outcomes. The position collaborates closely with clinical, intake, and billing teams to proactively resolve coding and coverage issues before services are rendered . Additionally, this role will t rain and onboard new Claims Coordinator staff on systems, processes, and best practices, while teaching the team and documenting process updates. Essential Job Functions ​List the essential functions for the job. Essential functions are the reason a job exists. § Review diagnosis and medication coding for infusion services, particularly when payer restrictions are identified , serving as the escalation point for complex or atypical scenarios. § Evaluate payer medical policies and CMS guidelines to determine medical necessity and coverage, providing expert interpretation for gray ‑ area or evolving policy situations. § Ensure accurate alignment between clinical documentation and billing codes prior to service delivery. § Coordinate and validate completion of Advance Beneficiary Notices (ABNs) in the system, including appropriate modifiers . § Apply advanced knowledge of Medicare guidelines and FDA label coverage to coding decisions, independently resolving exceptions and denials driven by off ‑ label or conditional coverage. § Collaborate with infusion intake, billing, and clinical teams to resolve coding discrepancies and advise on corrective documentation practices. § Identify , triage, and resolve complex reimbursement or compliance issues, escalating only when systemic or regulatory risk is identified . § Maintain accurate , defensible documentation to support coding decisions, audit readiness, and post ‑ payment review activities. § Support compliance with regulatory, payer, and organizational billing policies. § Participate in process improvement initiatives related to coding accuracy, reimbursement optimization, and intake standardization § Train and onboard new Claims Coordinator staff on systems, processes, and best practices. § Provide guidance and mentorship to Claims Coordinator specialists This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation. Licensing/Certification Active Certified Professional Coder (CPC) – American Academy of Professional Coders; Active Philippine Health Registry Number (PHRN) (required) Certified Outpatient Coder (COC) – American Academy of Professional Coders ; Certified Hematologyand Oncology Coder (CHONC) – American Academy of Professional Coders (preferred) Education Associate’s Degree (required) - Specialty/Major: Health Information Management, Medical Coding, or related field Bachelor’s Degree (preferred) - Specialty/Major: Health Information Management, Medical Coding, or related field Work Experience 3+ years of experience in medical coding, healthcare billing, or revenue cycle (required) 3 years of medical coding or hospital billing experience, including at least 1 year in hospital outpatient department (HOPD) infusion coding and 1 year of bedside experience (preferred) Training On-the-job training in coding systems, payer policies, and internal workflows (required) Advanced training in Medicare billing guidelines and infusion coding practices ; well-versed in Medical Coding Guidelines (MCG) (preferred) Language N/A (required) Spanish or other languages (preferred) As a Bon Secours Mercy Health associate, you’re part of a Mission that matters. We support your well-being – personally and professionally. Our benefits are built to grow with you and meet your unique needs, every step of the way. What we offer Comprehensive HMO medical coverage, retirement plan and group life and accident insurance One-time Work From Home allowance, connectivity allowance, wellness allowance and role-specific allowances Paid vacation and sick leave Government-mandated benefits: SSS, PhilHealth and Pag-IBIG contributions Flexible working model with hybrid, onsite or virtual arrangements (based on role and business need) Mission-driven culture events, community outreach and service opportunities Learning and development programs, mentorship and clear career growth pathways Modern, collaborative office spaces and regular engagement and culture-building activities Benefits may vary based on employment terms and role. Department: Human Resources - Talent Acquisition - BSMH Global Business Systems It is our policy to comply with all applicable Philippine labor laws and regulations and to uphold equal employment opportunity in all aspects of recruitment and employment. All applicants will be considered for employment based on merit, qualifications, and business requirements, without regard to race, color, ethnicity, religion, sex, sexual orientation, gender identity or expression, civil status, age, disability, genetic information, nationality, or any other status protected under Philippine law. We are committed to providing an inclusive workplace free from unlawful discrimination and harassment. If you are a person with a disability and require reasonable accommodation as part of the application or selection process, please contact the Talent Acquisition Team at [email protected] . We will work with you to provide appropriate assistance in accordance with applicable laws and company policy.