Head - Medical Support Center

1 month ago

Metro Manila, Philippines InLife Health Care Full time

JOB PURPOSE 

 

The Head of Medical Support Center is responsible in leading the team of Medical Support Center in providing effective and efficient support together with the rest of the departments of the Medical Services Division and the Sales and Marketing Division to insured members. They assist IHC members during outpatient availments mainly and ensures the proper implementation of the customer service experience and ensuring the proper and appropriate implementation of plan policies resulting to utilization management. 

 

JOB DESCRIPTION 

 

Take the lead in ensuring that IHC members availing of medical services in accredited medical facilities are assisted accordingly. 

Monitor proper manpower complement per shift based on the census of calls, emails and other forms of communication from accredited medical providers and IHC members. 

Ensure that members’ queries, concerns and/or complaints are attended to in a timely and appropriate manner prior to elevating this to the Medical Director. 

Keep abreast with current regulations and policies affecting medical services and implementation and provide proper guidance to all concerned. 

Continuously train the MICAs regarding medical updates, utilization management, newly onboarded and renewed account benefits. 

Coach MICAs to maintain company spiels and lines that will entice members to call them regarding their benefit including medical network inquiries, concerns and LOA issuances. 

Ensure that MICAs have discussed the member’s coverage and benefits and has issued the letter of authorization (LOA). 

Ensure the MICAs assist the member during their availment by checking medical facility charges and professional fees to maximize member’s benefits and to prevent incurrence of excess charges beyond the benefit coverage and advises member on non-covered charges. 

Build and maintain good rapport with IHC’s designated Hospital Care Director (HCD) in the hospital, IHC’s roster of accredited physicians and provider personnel. 

Create and organize processes, information acquisition and appropriate agreements to ensure alignment with the company's policies on Health & Safety, Quality Assurance, Marketing & Brand Management, and Risk & Integrity Management. 

Coach MICAs in the proper gatekeeping and utilization management through: 

Determination of validity of the member status, benefit coverage and maximum available limit prior issuance of LOAs through information garnered from the Medical Account System (MAS). 

Review of cases and checking necessity of availment and need for medical procedure. 

Coordination of catastrophic cases to the Medical Director for case management. 

 

Monitor distribution of service evaluation survey forms and ensure that the targeted confidence level and margin of error is met on a monthly basis. 

Receive comments, suggestions and feedback and collates survey results. 

Assist the Provider Management Division by: 

Increasing the roster of accredited medical facilities especially physicians. 

Instructing MICAs to do on the spot or provisional accreditation of member accessed/requested physicians and/or medical facilities. 

Updating the records of physicians as the need arises. 

Coordinating with accredited medical facilities for payment, OR follow-ups or lifting of suspensions. 

Work with internal and external leaders in areas affecting department operations. 

Together with the Medical Director and the other members of the Utilization Management Committee, create processes for Medical Audit and ensure proper application through an established and agreed medical audit exercise. 

Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Utilization Management responsibilities. 

Generate reports relative to duties and responsibilities. 

 

QUALIFICATIONS 

 

Education: Must be a graduate of Bachelor’s Degree in Nursing or any medical course. 

 

Experience:. With managerial experience. With related professional and corporate clinical experience. Demonstrated experience in operations and project management. Experience in insurance / HMO and value adding services preferred. 

 

Knowledge, Skills, and Abilities: 

Excellent communication, presentation, coordination, budget management and negotiation skills. 

"No-box" thinker, creative/non-traditional. 

Knowledge of medical terminologies and conditions with ability to relate cases, Utilization Management, Relationship Management, Customer Service 

Excellent knowledge of MS Office Applications 

Empathetic 

Adaptable and change oriented 

Controlled demeanor 

Customer service oriented 

With exceptional oral and written communication skills 

Interpersonal skills 

Pleasing personality 

Organizational skills /attention to details 

Decision making skills 

 

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