Claim Analyst

Claims Analyst is responsible for reviewing, assessing, and adjudicating health insurance claims in accordance with policy provisions, company guidelines, and regulatory requirements. This role ensures claims are processed accurately, fairly, and within established service standards, while maintaining compliance with internal procedures and risk controls.

In addition, the Claims Analyst works closely with customers, healthcare providers, and internal stakeholders to gather and validate claim information, resolve inquiries, and support timely claim resolutions. The role plays a key part in delivering a positive customer experience by balancing efficient claim handling with high standards of quality and service.

Position Responsibilities

• Review and assess health insurance claims submitted by members and healthcare providers.
• Verify the completeness and accuracy of supporting documents, including medical diagnoses, treatment records, investigation results, and medical expenses.
• Validate policy eligibility, benefits, coverage limits, exclusions, and applicable terms before making claim decisions.
• Determine claim outcomes, including approval, rejection, partial approval, or requests for additional information.
• Identify potential fraud, abuse, or irregular claim activities and escalates cases when necessary.
• Liaise with hospitals, clinics, healthcare providers, brokers, and policyholders to obtain additional information and resolve claim issues.
• Ensure claims are processed within the company's established Service Level Agreements (SLAs).
• Communicate claim decisions professionally and clearly to internal and external stakeholders.
• Ensure compliance with company policies, regulatory requirements, and governance standards.

Required Qualifications

• Bachelor's degree in Medicine, Nursing, or a related healthcare field.
• Experience in health insurance claims, managed care, TPA, or health insurance operations is preferred.
• Strong understanding of medical terminology, health insurance benefits, and claims adjudication processes.
• Excellent analytical and investigative skills with strong attention to detail.
• Proficient in Microsoft Office, particularly Excel.
• Self-motivated, collaborative, and proactive in driving outcomes.
• Willing to work under a contract employment arrangement.

Preferred Qualifications

• Strong communication, coordination, and stakeholder management skills

When you join our team:

• We’ll empower you to learn and grow the career you want.
• We’ll recognize and support you in a flexible environment where well-being and inclusion are more than just words.
• As part of our global team, we’ll support you in shaping the future you want to see.

マニュライフとジョン・ハンコックについて

マニュライフ・ファイナンシャル・コーポレーションは、「あなたの未来に、わかりやすさを」を提供する、国際的な大手金融サービスプロバイダーです。当社について詳しくは、

マニュライフは機会均等を是とする雇用主です

マニュライフ/ジョン・ハンコックでは、多様性を受け入れます。私たちは、サービス提供先であるお客さまと同様に、多様な人材を引きつけ、育成し、定着させ、文化や個人の力を受け入れる包括的な職場環境を促進するよう努めています。当社は公正な採用、定着、昇進、報酬に努めています。当社のすべての慣行およびプログラムは、人種、祖先、出身地、肌の色、民族的出自、市民権、宗教または宗教的信念、信条、性別（妊娠および妊娠関連の状態を含む）、性的指向、遺伝的特徴、退役軍人としての地位、性自認、性に関する表明、年齢、婚姻状況、家族状況、障害、または適用法で保護されるその他の要因に対する一切の差別を行うことなく管理されます。

雇用への平等なアクセスを提供するために、障壁を取り除くことが当社の優先事項です。人事担当者は、応募者が応募プロセス中に合理的配慮を要求する場合に協力します。配慮要求のプロセス中に共有されるすべての情報は、適用される法律およびマニュライフ/ジョン・ハンコックのポリシーに準拠した方法で保存および使用されます。申請プロセスにおいて合理的配慮を要求するには、Ver el correo electrónico en click.appcast.io。

Working Arrangement

ハイブリッド勤務

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Bachelor's degree in Medicine, Nursing, or related healthcare field
Analytical skills, Attention to detail, Excel, Microsoft Office, Communication skills, Team collaboration, Proactive
会員・医療提供者からの健康保険請求の審査と評価。, 医療診断・治療記録・調査結果・医療費の添付書類の完全性を確認。, 保険給付、適用条件、除外事項を確認し、請求判断を下す。, 承認・却下・部分承認・追加情報の要請を決定。, 不正の可能性の識別とケースのエスカレーション。, 病院・ clinics・仲介業者・契約者との情報収集と問題解決。, SLAsに従って請求処理を実施。, 内部・外部の関係者へ決定内容を適切に伝達。, 社内規程・規制要件・ガバナンス基準を遵守。