Manager Medical Management

Helpjuice; Taguig; On-site; PHP 1,000,000 - 1,800,000; Full time

Job summary

Helpjuice seeks a Manager Medical Management to lead a team of clinicians ensuring high quality, cost-effective member care. You will oversee utilization of inpatient and outpatient services, interpret medical policies, and steer members to appropriate providers and programs. A US RN license and substantial acute care experience are required.

The role emphasizes strong communication, problem-solving, and analytical skills to optimize benefits and resource use across settings.

Qualifications

• Requires current active unrestricted RN license to practice as a health professional within applicable US states.
• Requires 5 years of acute care clinical experience or an equivalent combination of education and experience.
• Strong oral, written and interpersonal communication skills, problem-solving, facilitation and analytical skills.

Responsibilities

• Lead and manage a team of clinicians focused on quality member outcomes, benefits optimization and resource use.
• Ensure adherence to medical policy and appropriate, cost-effective care.
• Coordinate care across facilities/providers, including care coordination and potential appeals handling.
• Hire, train, coach and evaluate performance of direct reports.

Skills

Interpersonal communication

Oral/Verbal communication

Written communication

Problem solving

Analytical skills

Education

RN license (US)

Job description

Position Title

Manager Medical Management

Job Description

Responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to: Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Applies clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied. Hires, trains, coaches, counsels, and evaluates performance of direct reports. Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States, except in government business where it is preferred, and 5 years acute care clinical experience or any combination of education and experience, which would provide an equivalent background. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. The following are level distinctions not required for posting. This level typically reflects a new manager, one managing a singular function, a manager with a smaller span of management, or one located in a unit where a higher level of management exists.For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.