HDSI: Provider Relations Manager

ActiveOne Health, Inc.; Mandaluyong; On-site; PHP 800,000 - 1,200,000; Full time

Job summary

ActiveOne Health, Inc. seeks a senior operations leader to oversee medical, financial, and strategic functions across claims adjudication, provider management, accreditation, and internal medical support in Metro Manila.

The role acts as a bridge between Clinical, Customer Service, Finance, and Provider Networks, guiding multi-department coordination and delivering data-driven recommendations to optimize operations and cost control.

Responsibilities

• Lead provider engagement initiatives (planning, organizing, and execution)
• Approve/deny reconciliation of accounts impacting provider payments
• Perform in-patient adjudication, including proper segregation of illnesses
• Review and approve facility accreditation and any changes
• Handle and resolve Customer Service (CS) medical concerns and escalations
• Review and evaluate contracts (providers)
• Screen, accredit, and onboard CCM and clinic management doctors
• Monitor PROs’ KRAs and overall performance
• Initiate and support NetSuite PRT module upgrades (medical validation and process alignment)
• Attend to medical needs of Flexicare employees
• Provide real-time medical guidance to CSRs
• Analyze utilization data and provide strategic recommendations to management
• Diagnose and adjudicate claims to ensure accuracy and cost control
• Ensure coordination across departments and business units for seamless operations

Job description

Job Objective / Purpose

To provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation, and internal medical support—serving as a critical bridge between Clinical, Customer Service, Finance, and Provider Networks.

Duties and Responsibilities

• Lead provider engagement initiatives (planning, organizing, and execution)
• Approve/deny reconciliation of accounts impacting provider payments
• Perform in-patient adjudication, including proper segregation of illnesses
• Review and approve facility accreditation and any changes
• Handle and resolve Customer Service (CS) medical concerns and escalations
• Review and evaluate contracts (providers)
• Screen, accredit, and onboard CCM and clinic management doctors
• Monitor PROs’ KRAs and overall performance
• Initiate and support NetSuite PRT module upgrades (medical validation and process alignment)
• Attend to medical needs of Flexicare employees
• Provide real-time medical guidance to CSRs
• Analyze utilization data and provide strategic recommendations to management
• Diagnose and adjudicate claims to ensure accuracy and cost control
• Ensure coordination across departments and business units for seamless operations