Medical Governance Consultant

A leading health insurance provider is seeking a Medical Governance Consultant to ensure clinical operations, provider decisions, and medical policies align with regulatory standards and evidence-based medicine. This hybrid role offers the opportunity to influence policy, strengthen clinical risk management, and improve patient safety within a collaborative, integrity-driven environment.

What You'll Do
As a Medical Governance Consultant, you will be entrusted with safeguarding the integrity of clinical operations by ensuring that every aspect of policy development, audit activity, and provider engagement meets rigorous regulatory standards. Your day-to-day responsibilities will involve collaborating with various internal teams to review existing frameworks, conduct detailed audits on claims and provider practices, lead investigations into complex cases such as quality incidents or disputes, and provide strategic guidance during key accreditation processes. By monitoring patient outcomes and supporting risk management initiatives through root-cause analysis, you will help drive continuous improvement in both patient safety and organisational accountability. Your ability to maintain clear documentation while navigating complex regulatory environments will be essential for success in this influential role.

• Develop, review, and update comprehensive medical policies, clinical guidelines, and benefit coverage rules to ensure alignment with current best practices and regulatory requirements.
• Ensure full compliance with Department of Health (DOH), Insurance Commission, PhilHealth, and all other applicable regulatory frameworks governing health insurance operations.
• Conduct thorough audits on medical claims, provider practices, and clinical decision documentation to identify areas for improvement and uphold high standards of care.
• Lead detailed investigations related to clinical quality incidents, suspected fraud cases, or medical disputes to support transparency and accountability.
• Work collaboratively with actuarial and claims teams to align governance policies with benefit design for optimal member experience and operational efficiency.
• Provide expert advisory support during provider accreditation processes, performance reviews, and clinical quality meetings to foster continuous improvement.
• Monitor patient outcomes through robust data analysis and reporting mechanisms to ensure ongoing assurance of clinical effectiveness.
• Support the implementation of risk management strategies by conducting root-cause analyses on adverse events or system failures.
• Maintain meticulous documentation of all governance activities in accordance with ethical standards and organisational protocols.

What You Bring
Your extensive experience as a licensed physician or senior clinician—particularly within regulated healthcare environments—will enable you to navigate complex policy landscapes with confidence. A solid foundation in HMO operations or insurance-related roles will allow you to understand the nuances of benefit design while your familiarity with clinical coding systems ensures accuracy in claims adjudication. Your proven ability to develop robust policies combined with hands-on experience conducting audits positions you as a trusted advisor capable of identifying risks before they escalate. Strong analytical skills underpin your approach to monitoring outcomes while your commitment to ethical practice guarantees that all documentation is handled responsibly. Your interpersonal strengths will shine when collaborating across teams or providing guidance during critical accreditation processes.

• Licensed physician (preferred) or senior clinician with substantial experience in healthcare regulation or governance is highly desirable for this position.
• Demonstrated background working within HMO settings, insurance organisations, hospital quality departments, or similar environments focused on clinical governance.
• Comprehensive understanding of clinical coding systems such as ICD-10 and CPT as well as benefit rules and claims adjudication processes.
• Proven track record in policy development encompassing drafting, reviewing, implementing, and updating medical guidelines or benefit coverage rules.
• Expertise in conducting clinical audits for compliance purposes along with monitoring patient outcomes using evidence-based methodologies.
• Experience in risk management including root-cause analysis of adverse events or systemic issues affecting patient safety or service delivery.
• Strong ethical judgement supported by excellent documentation skills ensuring transparency throughout all governance activities.
• Ability to provide advisory support during provider accreditation processes as well as participate actively in performance reviews or quality meetings.

What Sets This Company Apart
This organisation stands out for its unwavering commitment to upholding the highest standards of patient safety, accountability, and ethical practice within the health insurance sector. Employees are valued not only for their technical expertise but also for their dedication to fostering a culture built on trust, collaboration, and mutual respect. The company invests significantly in training opportunities designed to enhance both professional knowledge and personal growth while promoting flexible working arrangements that support work-life balance. With a focus on continuous improvement driven by transparent communication channels between leadership teams and staff members alike, this is an environment where your contributions are recognised—and where you can truly make a difference in shaping the future of healthcare governance. The organisation's inclusive ethos ensures that every voice is heard while generous benefits packages reflect their appreciation for your hard work. Join a team where your passion for responsible healthcare delivery is matched by genuine opportunities for advancement within an industry-leading framework.

What's Next
If you are ready to bring your expertise in medical governance to an organisation committed to excellence in healthcare delivery—apply now

Apply today by clicking on the link provided; take the next step towards making a lasting impact on patient safety and organisational accountability.

Due to the high volume of applications we are experiencing, our team will only be in touch with you if your application is shortlisted.