HDSI: Provider Relations Manager

ACTIVEONE HEALTH, INC.; Mandaluyong; On-site; PHP 669,600 - 892,800; Full time

Job summary

ACTIVEONE HEALTH, INC. in Mandaluyong, Philippines is seeking a professional to provide end-to-end medical, operational, and strategic oversight relating to claims adjudication and provider management. This role involves leading provider engagement, approving reconciliation impacting payments, and ensuring overall department coordination.

The ideal candidate will manage various responsibilities including accreditation, customer service concerns, and strategic recommendations based on utilization data. Strong analytical skills and medical guidance are essential for success in this position.

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.

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