Medical Management Manager

Job Summary Reports directly to the Health Plan Administrator and is responsible for performing complex medical management activities related to authorization of treatment requests to ensure efficient use of patient utilization systems, and quality care using appropriate medical resources. Also responsible for providing assistance in evaluating the quality of medical care and utilization, and ensures conformance with organizational policies and guidelines and compliance with government regulations. Supervises and monitors daily utilization activities in the department, tracks and evaluates staff performance related to utilization review, processing, approval, and denials. Responsibilities Review and analyze medical information and assist in evaluating the medical necessity of service treatment requests to ensure that treatments are consistent with the patient’s diagnosis. Determine the appropriateness of services based on the consistent application of the decision support system and communicate this to providers and patients in a timely and effective manner. Review financial and utilization data and prepare analyses of comparisons versus benchmark data; develop and recommend initiatives and programs to create improvement action plans. Perform telephonic and/or onsite reviews of basic to routine concurrent patient services and retrospective quality of care issues, access and outcome studies (e.g., HEDIS, NCQA). Maintain ongoing database/documentation to monitor all activities, treatment, and outcome plans for patients in conformance with organizational policies, guidelines, and government regulations. Develop and maintain quality assurance measures to ensure consistency in decision-making on requests for medical services using evidence-based guidelines, criteria, and decision support systems. Develop and implement tracking and control procedures to ensure services provided to eligible members are within the scope of the benefit plan and contracted providers are being utilized. Oversee the coordination and concurrent review of patients to ensure services are provided at the appropriate level of care, utilizing evidence-based guidelines and criteria. Provide feedback to physicians, providers, facilities, and members regarding authorization processes and treatment plans. Provide oversight on the Case Management Program to proactively identify and refer catastrophically and chronically ill patients to case management using established criteria. Oversee provider network development for the Philippines to include hospital facilities, clinics, and/or physician specialists. Assist in developing industry-recognized benchmarks for program tracking of caseloads, cost savings, and utilization. Qualifications Graduate of a Bachelor’s Degree in Nursing (or related field) with required license. Minimum of 10 years of experience with a proven track record in basic to routine medical management activities related to authorization of treatment requests. Supervisory and management experience preferred. Effective team player with strong interpersonal skills and ability to work well with coworkers, patients, and customers. 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. Basic familiarity with federal and state laws and requirements related to healthcare management. Computer literate and highly proficient in using MS Office programs. Management Evaluate staffing needs and schedule to ensure adequate department coverage. Evaluate staff performance and conduct reviews according to company guidelines and protocols. Supervise daily department activities to ensure completion of deliverables based on established benchmarks. Establish departmental goals and metrics and ensure necessary tracking is in place to achieve or exceed these goals, including formulation of action plans to address any deficiencies. Monitor team performance and develop streamlined processes through an improved workflow. Monitor and troubleshoot moderate to complex department issues in collaboration with the Medical Management Manager. Organize and implement regular communication sessions with Health Plan Administrator, Medical or Associate Medical Director, Medical Management Staff, and other healthcare team members, providing a venue to discuss issues and concerns in a timely and effective manner. Conduct departmental staff development and enrichment training as needed, keeping individual goals aligned with departmental and organizational objectives. Location Manila, National Capital Region, Philippines Seniority Level Mid‑Senior Employment Type Full‑time Job Function and Industries Health Care Provider; Hospitals and Health Care #J-18808-Ljbffr