Manager Medical Management

Helpjuice; Taguig; On-site; PHP 3,769,000 - 5,653,000; Full time

Job summary

Helpjuice is seeking a Manager Medical Management in a leadership role overseeing a team of clinicians to optimize member outcomes and resources. You will ensure services align with medical policy, promote cost-effective care, and coordinate with facilities for care management.

Qualifications include an active US RN license and 5 years of acute care experience or an equivalent mix, with strong communication and analytical skills for effective leadership.

Qualifications

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

Responsibilities

• Lead a team of clinicians to promote quality member outcomes and optimize benefits.
• Ensure medical policy adherence, cost-effective and high-quality service.
• Authorize inpatient admissions, outpatient services, and select procedures.
• Coordinate care with facilities and providers for care management and outcomes.

Skills

RN license (US)

Clinical management

Communication skills

Analytical skills

Job description

Position Title:

Manager Medical Management

Shift:

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.