Health Care Representative - Pasig

iCare HMO; Metro Manila; On-site; PHP 312,000 - 580,000; Full time

Job summary

iCare HMO is seeking an HMO Coordinator / Member Relations Representative to provide administrative support to the Hospital Liaison Officers and Medical Services Division. You will assist insured members during availments, ensuring proper customer service and adherence to plan policies.

The role focuses on utilization management, member communication, and coordination with accredited facilities, physicians, and provider management for efficient service delivery.

Qualifications

• Graduate of any 4-year college course (preferred).
• Experience in insurance / HMO and value-adding services preferred.
• BPO experience handling healthcare accounts is an advantage but not required.
• Okay for project-based employment.
• Can start ASAP.

Responsibilities

• Provide effective administrative support to Hospital Liaison Officers and Medical Services/ Sales and Marketing Divisions.
• Assist members during availments and ensure proper customer service implementation.
• Ensure member queries and complaints are attended to promptly and guided appropriately.
• Maintain up-to-date knowledge on medical updates, utilization management, and plan benefits.
• Issue LOAs and assist MD scheduling of appointments and other services.
• Support utilization management through gatekeeping and review of cases for necessity and coverage.
• Build rapport with hospital directors, providers, and rostered physicians; assist provider management with accreditation and records updates.
• Monitor claims status and inform members of acceptances/denials and disbursements.

Skills

Communication

Coordination

Negotiation

Education

4-year college degree

Job description

• Graduate of any 4-year college course, medical allied (preferred).




• Experience in insurance / HMO and value-adding services preferred.




• Good communication, coordination, and negotiation skills.




• With BPO experience handling healthcare account is an advantage but not required.




• Okay for project-based employment.




• Can start ASAP

A. JOB PURPOSE

The HMO Coordinator or Member Relations Representative (MRR)/HMO Officer is responsible for providing effective and efficient administrative support to the Hospital Liaison Officers Department together with the rest of the departments of the Medical Services Division and the Sales and Marketing Division to insured members. They assist iCare members during their availments mainly and ensure the proper implementation of Customer Service. Experience and ensure the proper and appropriate implementation of plan policies resulting in utilization management.

B. 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.

1. Customer Service

1.1. Ensure that iCare members availing of medical services in accredited medical facilities are assisted accordingly.

1.2. Ensure that members’ queries, concerns and/or complaints are attended to in a timely and appropriate manner prior to elevating this to the Medical Director.

1.3. Keep abreast with current regulations and policies affecting medical services and implementation and provide proper guidance to all concerned.

1.4. Be up to date on medical updates, utilization management, newly onboarded and renewed account benefits.

1.5. Maintain company spiels and lines that will entice members to call them regarding their benefit including medical network inquiries, concerns and LOA issuances.

1.6. Ensure that the member’s coverage and benefits is discussed appropriately and issue the letter of authorization (LOA).

1.7. Assist 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.

1.8. Issue LOAs and assist members for MD scheduling of appointments and other services.

1.9. Distribute service evaluation survey forms and ensure that the targeted confidence level and margin of error is met on a monthly basis.

1.10. Receive comments, suggestions and feedback and collates survey results.

2. Utilization Management

2.1. Ensure proper gatekeeping and utilization management through:

2.1.1. 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).

2.1.2. Review of cases and checking necessity of availment and need for medical procedure.

2.1.3. Coordination of catastrophic cases to superior for case management.

2.2. Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Utilization Management responsibilities.

3. Relationship Management

3.1. Build and maintain good rapport with iCare’s designated Hospital Care Director (HCD) in the hospital, IHC’s roster of accredited physicians and provider personnel.

3.2. Assist the Provider Management Division by:

3.2.1. Increasing the roster of accredited medical facilities especially physicians.

3.2.2. Do on the spot or provisional accreditation of member accessed/requested physicians and/or medical facilities.

3.2.3. Updating the records of physicians as the need arises.

3.2.4. Conducting initial claims for reimbursement screening submitted by members and inform members of any lacking documents, if any.

3.2.5. Monitor claims and inform members of acceptance/denial and release of checks.