Medical Management Specialist I/ PHRN

Carelon Global Solutions Philippines Inc; Taguig; On-site; PHP 300,000 - 420,000; Full time

Job summary

Carelon Global Solutions Philippines Inc. is seeking a Medical Management Specialist I/ PHRN to support Medical Management and Operations teams with non-clinical tasks. You will gather case information, refer cases, provide program details, and maintain databases.

The role emphasizes administrative duties over clinical interpretation and requires a Philippines RN license. Candidates should have at least 1 year of admin and customer service experience and knowledge of managed care concepts.

Qualifications

• Requires current Philippines RN license.
• At least 1 year of administrative and customer service experience.
• Knowledge of managed care or Medicaid/Medicare concepts.
• Strong communication and problem-solving skills.

Responsibilities

• Gathers clinical information regarding case and determines appropriate area to refer or assign case.
• Provides information regarding network providers or general program information when requested.
• May assist with complex cases.
• May act as liaison between Medical Management and/or Operations and internal departments.
• Maintains and updates tracking databases.
• Prepares reports and documents all actions.
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.

Skills

RN license

Administrative experience

Customer service

Managed care concepts

Job description

Position Title: Medical Management Specialist I/ PHRN Shift:

Job Description:

Responsible for providing non-clinical support to the Medical Management and/or Operations areas. Primary duties may include, but are not limited to: Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). Provides information regarding network providers or general program information when requested. May assist with complex cases. May act as liaison between Medical Management and/or Operations and internal departments. Maintains and updates tracking databases. Prepares reports and documents all actions.

Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.

Requires a current Philippines RN license; 1 year of administrative and customer service experience with knowledge of managed care or Medicaid/Medicare concepts; or any combination of education and experience, which would provide an equivalent background.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Care meets innovation

Our name translates to “providing full and complete care” and reinforces our commitment to putting people first in all that we do. We specialize in contact center operations (call and chat) and clinical nurse operations for Elevance Health. With four offices in prime locations across the Philippines—two in Manila and two in Iloilo— we boast a talent pool of more than 9,000 associates all working together to improve healthcare operations.

We use the right balance of care, technology, data, and expertise to streamline experiences and create value for our clients, people, and community. We also recognize the value that our associates bring, and that is why we are committed to providing the same through competitive compensation and comprehensive benefits such as rewards and recognition programs, health and medical insurance, and best-in-class amenities to keep associates and their families healthy and secure.

We celebrate and leverage our associates' limitless skills, talents, unique perspectives, and experiences. By respecting our people's culture and background, we foster a collaborative and purpose-driven workplace where everyone can grow and thrive in their careers.

If you are a recent senior high school or college graduate looking to get a head start in your career, we are the right team for you. Our people-first approach supports professional development by providing associates with the right tools and training that align with their aspirations.