HDSI: Provider Relations Manager

Reliance United; Manila; On-site; PHP 600,000 - 800,000; Full time

Job summary

Reliance United in Metro Manila, Philippines, is seeking a qualified professional to oversee claims adjudication, provider management, and internal medical support. The role will involve leading initiatives, handling customer service medical concerns, and analyzing utilization data for strategic recommendations.

The ideal candidate should ensure coordination across departments for seamless operations while providing medical guidance to staff.

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