JOB PURPOSE:
Preferably an experienced employee specializing in Healthcare and Insurance/HMO - Nurse/Medical Support & Assistant or equivalent. The Medical and Provider Services Representative (MPSR) is responsible for providing effective and efficient administrative support to the Medical and Provider Services Division along with the rest of iCare. They assist iCare members during their availment, mainly on LOA issuance, concerns resolution, and to ensure the proper implementation of good customer service. The incumbent shall also ensure the proper and appropriate implementation of plan policies related to utilization management.
DUTIES AND RESPONSIBILITIES:
This role will ensure that iCare members are assisted during their availment to contribute to employee engagement, and retention in proportion but not limited to the medical needs of the company and covered companies and individuals.
I. Customer Service
a) Acts as reliever for Member Relations Representatives (MRR) deployed in identified clients.
b) Ensures that iCare members availing of medical services in accredited medical facilities are assisted accordingly
c) Ensures that members’ queries, concerns and/or complaints are attended to in a timely and appropriate manner prior to elevating this to the Medical Director.
d) Keeps abreast with current regulations and policies affecting medical services and implementation and provides proper guidance to all concerned.
e) Be up to date on divisional concerns/directives, utilization management, newly onboarded and renewed account benefits.
f) Maintains company spiels and lines that will entice members to call them regarding their benefit including medical network inquiries, concerns, and LOA issuances.
g) Ensures that the member’s coverage and benefits are discussed appropriately and issue the letter of authorization (LOA) in a timely manner.
h) Assists 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.
i) Issues LOAs and assist members for MD scheduling of appointments and other services as necessary.
j) Assists HR of Clients in HMO related concerns which may include but is not limited to distribution of HMO ID, facilitate employee movement requests as endorsed by HR, scheduling of ECU/APE appointments, etc.
k) Ensures timely and proper encoding of members’ availment to support accurate reporting and effective utilization management strategies.
l) Prepares and maintains monthly census and accomplishment reports as required by the client assigned to.
m) Conducts initial claims for reimbursement screening submitted by members and informs members of any lacking documents, if any.
n) Monitors claims and inform members of acceptance/denial and release of checks.
o) Distributes service evaluation survey forms and ensures that the targeted confidence level and margin of error is met monthly.
p) Receives comments, suggestions and feedback and collates survey results.
II. Utilization Management
a) Ensures 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 superior for case management.
b) Participates in current process review and development of new and / or revised work processes, policies and procedures relating to Utilization Management responsibilities.
III. Relationship Management
a) Builds and maintains good rapport with iCare’s designated Hospital Care Director (HCD) in the hospital, iCare’s roster of accredited physicians and provider personnel.
b) Assists the Provider Management Division by:
- Increasing the roster of accredited medical facilities especially physicians.
- 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.
- Conducting orientation/ re-orientation of Accredited Providers.
JOB REQUIREMENTS:
- Graduate of any 4-year college course, preferably medical allied.
- Experience in insurance / HMO and value adding services preferred.
- Proficient in MS Office Programs (MS Word, Excel and PowerPoint)
- Good communication, coordination and negotiation skills. e) "No-box" thinker, creative/non-traditional.
Job Type: Full-time
Work Location: In person
