Provider Network & Clinical Operations Lead

RELIANCECARE INC.; Mandaluyong; On-site; PHP 800,000 - 1,200,000; Full time

Job summary

RELIANCECARE INC. in the Philippines seeks a licensed physician to oversee claims adjudication, provider management, accreditation, and internal medical support. You will bridge Clinical, Customer Service, Finance, and Provider Networks, driving end-to-end medical oversight.

The role focuses on provider engagement, adjudication, accreditation, and medical guidance to CSRs, with emphasis on strategic utilization and contract review in a health insurance/HMO context.

Qualifications

• Licensed physician with experience in health insurance or HMO.

Responsibilities

• Lead provider engagement initiatives (planning, organizing, and execution).
• Approve/deny reconciliation of accounts impacting provider payments.
• Perform in-patient adjudication, including proper segregation of illnesses.
• Review and approve facility accreditation and any changes.
• Handle and resolve Customer Service medical concerns and escalations.
• Review and evaluate contracts (providers).
• Screen, accredit, and onboard CCM and clinic management doctors.
• Monitor PROs' KRAs and overall performance.
• Provide real-time medical guidance to CSRs.
• Analyze utilization data and provide strategic recommendations to management.

Skills

Licensed physician

Education

Medical degree

Job description

RELIANCECARE INC. in the Philippines seeks a licensed physician to oversee claims adjudication, provider management, accreditation, and internal medical support. You will bridge Clinical, Customer Service, Finance, and Provider Networks, driving end-to-end medical oversight.

The role focuses on provider engagement, adjudication, accreditation, and medical guidance to CSRs, with emphasis on strategic utilization and contract review in a health insurance/HMO context.