Medical Review Specialist

1 month ago


Metro Manila, Philippines TakeCare Asia Philippines, Inc. Full time

Job Specifications:

Graduate of Bachelor’s Degree – RN License is required.Minimum of 2 years experience and must have impressive track record in reviewing treatment plans and services to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources.Effective team playerExcellent interpersonal relationship skills and can work and relate well with co-employees, patients, and customers.Must have behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.Outstanding oral and written communication skills.Strong ethics and a high level of personal and professional integrity.Must have basic familiarity on government rules and regulations relating to healthcare management.Proficient in using MS office programs

Duties and Responsibilities:

1. Medical Referral

1.1 Inputs and processes authorization requests and authorizations per guidelines and according to defined time and accuracy standards.

1.2 Reviews the health plan and other guidelines to ensure that services being provided to eligible members are within the scope of the benefit plan and contracted providers are being utilized. 

1.3 Issues letters of authorization and applies appropriate contracted or negotiated rates using established criteria.

1.4 Provides members with verification of eligibility, interpretation of benefits, and appropriate contracted provider/facility.

1.5 Screens and troubleshoots calls or walk-in’s regarding member care within scope of position. Routes members and provider concerns outside that scope to appropriate department or co-employees.

1.6 Maintains effective communication with members, providers, and other TakeCare staff to ensure adherence to company policies, guidelines and processes.

1.7 Corresponds with TakeCare Guam for coordination of members’ off-island referrals.

1.8 Administers reports and maintains files of correspondence, medical records, and other documentation, as appropriate, to report status and to support workflow.

2. Medical Review/Medical Management

2.1 Supports the Medical Review Specialist II, Medical Review Supervisor and other members of the Medical Review/Medical Management Team in the review and analysis of medical information in order to determine the medical necessity of continued stay according to review standards. 

2.2 Works with the Medical Review/Medical Management Team to determine medical necessity and length of stay based on the consistent application of decision support system and communicates decisions to providers and patients.

2.3 Works with the Medical Review/Medical Management Team in the coordination of discharge planning with physicians, members, families, caregivers and ancillary providers to support the member’s continuity of care needs.

2.4 Provides reports on quality-of-care issues. Submits reports and communicates in a timely and effective manner to the Manager of the Medical Referral Office.

2.5 Performs telephonic and onsite review of concurrent patient services and retrospective quality care issues, access, and outcome studies.

2.6 Maintains ongoing database/documentation to monitor all activities/treatment and outcome plans for patients’ conformance with organizational and government regulations.

2.7 Ensures that services provided to eligible members are within the benefit plan and appropriate contracted providers are being utilized.

2.8 Coordinates out of area cases ensuring patient receives cost-effective quality care and monitor patient for return to work.

3. Performs other duties that may be assigned from time to time.



  • Metro Manila, Philippines Makati Medical Center Remote Work Freelance Full time

    Job DescriptionResponsible for examining and analyzing the patient medical records for timeliness, accuracy and completenessPrepares report summaries presentations and needed forms of identified compliance and non-compliance of Patient Medical RecordsQualificationsGraduate of any Healthcare related courseWith work experience handling medical records...


  • Manila, National Capital Region, Philippines TakeCare Asia Philippines, Inc. Full time

    Job Specifications:Graduate of Bachelor's Degree – RN License is required.Minimum of 2 years experience and must have impressive track record in reviewing treatment plans and services to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources.Effective team playerExcellent interpersonal relationship...


  • Manila, National Capital Region, Philippines Makati Medical Center Full time

    Job DescriptionResponsible for examining and analyzing the patient medical records for timeliness, accuracy and completenessPrepares report summaries presentations and needed forms of identified compliance and non-compliance of Patient Medical Records Qualifications Graduate of any Healthcare related courseWith work experience handling medical records...


  • Metro Manila, Philippines Aljeron Medical Enterprises, Inc. Full time

    Role DescriptionThis is a full-time on-site role for a Regulatory Affairs Specialist at Aljeron Medical. The Regulatory Affairs Specialist will be responsible for handling regulatory documentation, ensuring regulatory compliance, and understanding and meeting regulatory requirements. He/She/They will be responsible for spearheading all regulatory activities...

  • medical specialist ii

    1 month ago


    Manila, National Capital Region, Philippines Valenzuela City Medical Center - Government Full time

    MEDICAL SPECIALIST II - PART TIME in NCR For full job description please see PDF file on Civil Service Commission site by clicking on this job ad. To apply, please kindly follow the procedure described in the PDF file.


  • Manila, National Capital Region, Philippines Marine Medical Services Full time

    JOB REQUIREMENTS:Candidate must possess a Bachelor's Degree. Fresh graduates are encouraged to apply.A Medical Allied Degree holder is a plus.Must have good command of the English language.Willing to undergo training prior to employment.To work in a Maritime Clinic. JOB RESPONSIBILITIES:Assessing patients in need of medical care.Assisting and scheduling...


  • Metro Manila, Philippines AGS health Full time

    QualificationsAt least 1 year of relevant BPO experience as a Utilization Review NursePHRN licensed Willing to report onsite and on a night shift scheduleJob DescriptionProvide health care utilization review services regarding admissions, observations, Discharge Wqs based on the payer types and review types. Review admissions and service requests within...


  • Metro Manila, Philippines Medical & Business Virtual Assistants 24-7 Full time

    Company Overview:We are a company built on trust and loyalty. MBVA 24/7 started in 2018 and has continuously fostered skilled and talented Virtual Assistants for many clients. Our team of virtual assistants provides services all over the US, and we sure won’t be stopping there! Our main office is located in Arizona and Manila. We have a legion of virtual...


  • Metro Manila, Philippines Aljeron Medical Enterprises, Inc. Full time

    Role Description This is a full-time on-site role for a Medical Device Sales Representative at Aljeron Medical located in Mandaluyong. The Sales Representative will be responsible for promoting and selling medical devices, with a focus on Urology, OB-GYN, and general surgical equipment. Daily tasks include engaging with clients, demonstrating product...


  • Metro Manila, Philippines ELEVATE AND DELEGATE LLC Full time

    Overview: We are seeking a skilled and dedicated Medical Billing Specialist to join our healthcare administration client. In this role, you will be responsible for managing the entire billing process, including preparing and submitting claims, following up on unpaid claims, and ensuring accurate patient billing. This position requires strong analytical...


  • Metro Manila, Philippines Insular Life Assurance Co., Ltd. Full time

    JOB PURPOSE:The Medical Services Specialist will provide support to the Medical and Underwriting Division by servicing internal and external customers, coordinate with external service providers, and perform various administrative and underwriting functions.  PRINCIPAL ACCOUNTABILITIES:Provide support through a variety of tasks that deal with employees and...

  • CPC Medical Coder

    4 weeks ago


    Metro Manila, Philippines CF Solutions Philippines Inc. Full time

    Responsibilities:Review medical charts and records thoroughly to ensure accuracy, completeness, and adherence to regulatory standards and internal policies.Identify and report discrepancies, errors, and inconsistencies in medical documentation to relevant stakeholders.Collaborate with healthcare professionals, such as physicians, nurses, and medical coders,...

  • Medical Biller

    2 weeks ago


    Metro Manila, Philippines Phoenix Virtual Solutions Full time

    DescriptionThe Medical Billing and Collection Specialist is responsible for a broad range of billing functions by providing operational support through the full billing cycle: duties include collections, payment posting, billing, claim submissions, medical insurance communications, and other billing matters. In this role, the Specialist is responsible to...


  • Metro Manila, Philippines Makati Life Nurture Medical Center Inc. Full time

    Company DescriptionMakati Life Medical Center is a state-of-the-art healthcare facility in Metro Manila, where patients are the top priority. The hospital is equipped with the finest medical technology, facilities, and doctors to assist everyone's healthcare needs effectively.BASIC FUNCTION:The Medical Concierge Manager acts as a liaison between patients,...


  • Metro Manila, Philippines Remote Bears Remote Work Freelance Full time

    Job descriptionDuties and responsibilities:The medical Billing and collection specialist is responsible for monitoring claim status, researching rejections and denials, documenting related account activities, posting adjustments and collections of Medicare, Medicaid, Medicaid Managed Care, commercial insurance, and Work Comp payers.Key Success Indicators /...


  • Metro Manila, Philippines AGS health Full time

    QualificationsAt least 1 year of relevant BPO experience as a Utilization Review NursePHRN licensed Willing to report onsite and on a night shift scheduleJob DescriptionProvide health care utilization review services regarding admissions, observations, Discharge Wqs based on the payer types and review types. Review admissions and service requests within...


  • Manila, National Capital Region, Philippines AGS health Full time

    QualificationsAt least 1 year of relevant BPO experience as a Utilization Review NursePHRN licensed Willing to report onsite and on a night shift scheduleJob DescriptionProvide health care utilization review services regarding admissions, observations, Discharge Wqs based on the payer types and review types. Review admissions and service requests within...


  • Manila, National Capital Region, Philippines AusMed Medical Support Group Full time

    AusMed Medical Support Group is an Australian company that provides virtual off-site admin support services to health care providers, medical clinics and allied health professionals.AusMed's mission is delivered by a team of efficient virtual administration assistants and reliable IT specialists.Due to the increased demand within our business, AusMed is...


  • Metro Manila, Philippines Phoenix Virtual Solutions Full time

    This is a remote position. Medical Billing and Coding Specialist Description The Medical Billing and Coding Specialist plays a vital role in ensuring the accuracy and efficiency of the billing cycle, from coding patient records to handling collections and payment posting. This role encompasses a broad range of responsibilities, including assigning...


  • Metro Manila, Philippines WHR Global Consulting Full time

    WHR Global Consulting, a global talent solution provider is looking for a stellar candidate to fill the role of Marketing Specialist for Medical Device for its client based in NCR areas.This is for direct hiring and for a role.Requirements:- Bachelor’s degree graduate of any 4 year course, allied medical course but not preferred.- Has at least 2 years...