Medical Claims

2 weeks ago

Makati City, National Capital Region, Philippines HEALTH MAINTENANCE, INC. Full time

I. Work Objectives:

1. Ensures efficient operation of Medical Ancillary & Support Services Division management fromeworks (claims processing, reimbursement processing and underwriter.

2. Manages initiatives in enabling MASSD team to define governance for the strategic processing of the accurate and timely payment of claims.

3. Keeps abreast of any changes in the schedule of payments of providers.

4. In depth knowledge on the approach of clinical cases and interpretation of medical information relevant to the claims.

5. Deep and solid knowledge of the overall division's function.

II. Duties and Responsibilities

A. CLAIMS Department

1. Reviews and approves all processed and checked bills (e.g. in-patient bills, professional fees, various out-patient, annual physical exam.)

2. Identifies and addresses issues concerning fraud, waste and abuse.

3. Coordinates the necessary communication for all affected parties related to claims disputes.

4. Make sure that professional fees of specialists basing on their affiliation with HMO organization and hierarchy are being followed accordingly.

5. Recommends fees based on relative value (RUV) and existing guidelines on benchmarked rates for procedures.

6. Analyzes claims utilization data, determines drivers of utilization costs, top availers, type of availments, top providers and other parameters deemed necessary.

7. Formulates strategies and recommendations to control and decrease healthcare utilization costs.

8. Manages complaints arising from any claims payment or non-payment.

9.Plans or strategizes effective and timely processing of bills.

10. Evaluates TATS, gaps, and manages escalated issues through collaboration with relevant divisions.

11. Writes and sends letters regarding their concerns.

12. weekly meeting with the MASSD staff concerning their target daily output, their concerns and problems with the healthcare providers and hospital affiliates.

13. Attends operations committee meeting weekly.

14. Discusses and re-evaluates annual performance given by the senior assistant manager and supervisor.

B. UNDERWRITER Department

1. Together with the Medical Underwriter, monitors, evaluates and discusses health status of member/s of incoming accounts and for the renewal of membership.

2. Evaluates members who are turning age of 60 and above based on their risk conditions, utilizations. length of membership and history of premium payments.

3. Explains to members their membership status and reasons for disapproval of membership.

4. Discusses with Recon Committee for the final approval of disapproved membership or for continuation of membership.

C. REIMBURSEMENT Department

1. Discusses the case with the team, evaluates, provides expert's medical opinions and medical references referrable to the cases and provides reasons for the approval or disapproval of cases.

2. Reconsiders cases for evaluation based on medical references and medical expert's opinions.

3. Handles appeals for cases that did not fall within the parameters defined in the claims guidelines or cases whose earlier decision rendered are disputed hence requested for review by the reconsideration committee.

4. Discusses and evaluates cases that will be elevated to the Reconsideration Committee.

5. In charge of the letters to be sent to the member for the approved and disapproved cases presented to reconsideration committee.

6. Makes the minutes of the recon meeting.

7. Attends operations committee meetings and other meetings deemed necessary for the improvement of the MASSD process flow and the system of the HMI management as well.

8. Performs related duties as directed by the President.

III. COMPETENCIES required

1. Must be a Medical Specialists, an Active consultant for 5 years and preferably part of the surgical team or exposed to Operative Procedures or a Medical Doctor with at least 8 years of experience as a head of Medical Claims.

2. Must possess high degree of professionalism and competency.

3. Must demonstrate good verbal and written communication skills.

4. Proficiency in reading, writing, and arithmetic in order to investigate and understand medical conditions.

5. Must possess good customer service skills.

6. Ability to handle multiple tasks at once.

7. Ability to work effectively and efficiently, independently as well as part of the team.

8. Must be able to perform other tasks as deemed necessary by the management.

IV. QUALIFICATIONS

1. A graduate of Doctor of Medicine

2. Had specialty trainings preferably in Surgery. Ob-Gyne and Pediatrics.

3. Knowledgeable of complex disease conditions, treatments, tests and medications.

4. With high attention to details.

5. Excellent oral and written communication skills.

6. Ability to multi-task.

7. Computer literate with proficiency in MS Office, using MS word and excel.

8. Strong analytic skills.

Job Types: Full-time, Permanent

Benefits:

  • Additional leave
  • Health insurance
  • Life insurance
  • Opportunities for promotion
  • Pay raise
  • Promotion to permanent employee

Schedule:

  • Day shift
  • Monday to Friday

Supplemental pay types:

  • 13th month salary

Application Question(s):

  • Asking salary for the position you are applying for

Education:

  • Doctorate (Preferred)

Experience:

  • medical: 5 years (Preferred)

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