HMO Representative - Client Based

Inlife Health Care; Cebu City; On-site; PHP 400,000 - 600,000; Full time

Job summary

Inlife Health Care is seeking an HMO Coordinator to provide administrative support across multiple departments, ensuring effective member assistance and compliance with service standards. This role involves engaging with healthcare providers, managing member queries, and supporting utilization management for insured individuals, with an emphasis on excellent communication and coordination skills.

Qualifications

• Experience in insurance/HMO and value-adding services preferred.
• With BPO experience handling healthcare accounts is an advantage but not required.
• Okay with project-based employment.

Responsibilities

• Assist IHC members availing medical services in accredited facilities.
• Attend to members’ queries, concerns, and complaints promptly.
• Ensure proper gatekeeping and utilization management.

Skills

Communication

Coordination

Negotiation

Education

Graduate of any 4-year college course

Medical allied (preferred)

Job description

JOB REQUIREMENTS:

• 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 accounts is an advantage but not required.
• Okay with project-based employment.
• Work assignment: Cebu IT Park
• 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, as well as the Medical Services Division and the Sales and Marketing Division, to insured members. They assist IHC members during their availments and ensure the proper implementation of the “Magandang Araw” Customer Service, including experience and compliance with plan policies resulting in utilization management.

B. DUTIES AND RESPONSIBILITIES

This role ensures that IHC members are assisted during their availment to contribute to employee engagement and retention, focusing on the medical needs of the company and covered individuals.

1. Customer Service

1.1. Assist IHC members availing medical services in accredited facilities.

1.2. Attend to members’ queries, concerns, and complaints promptly and appropriately, escalating to the Medical Director if necessary.

1.3. Stay updated on current regulations and policies affecting medical services and provide guidance accordingly.

1.4. Keep abreast of medical updates, utilization management, and benefits related to onboarded and renewed accounts.

1.5. Maintain effective communication lines to encourage members to call regarding their benefits, medical network inquiries, concerns, and LOA issuances.

1.6. Ensure proper discussion of member coverage and benefits, and issue LOAs.

1.7. Assist members during their medical service with charges verification and benefit maximization, advising on non-covered charges.

1.8. Issue LOAs and assist with MD appointment scheduling and other services.

1.9. Distribute service evaluation surveys and meet targeted confidence levels and margins of error monthly.

1.10. Collect and collate comments, suggestions, and feedback from surveys.

2. Utilization Management

2.1. Ensure proper gatekeeping and utilization management through:

2.1.1. Validating member status, benefit coverage, and limits before issuing LOAs using the Medical Account System (MAS).

2.1.2. Reviewing cases for necessity of procedures and treatments.

2.1.3. Coordinating catastrophic cases for case management.

2.2. Participate in process reviews and the development of new or revised policies and procedures related to Utilization Management.

3. Relationship Management

3.1. Build and maintain good rapport with IHC’s Hospital Care Director (HCD), accredited physicians, and provider personnel.

3.2. Support Provider Management by:

3.2.1. Expanding the roster of accredited medical facilities and physicians.

3.2.2. Conducting provisional accreditation of physicians and facilities.

3.2.3. Updating physician records as needed.

3.2.4. Screening initial reimbursement claims and informing members of missing documents.

3.2.5. Monitoring claims and informing members of acceptance or denial and check releases.