Provider Relations & Medical Claims Lead

RelianceUnited; Mandaluyong; On-site; PHP 600,000 - 900,000; Full time

Job summary

RelianceUnited in Manila seeks a senior health operations leader to provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation, and internal medical support, acting as a vital bridge between Clinical, Customer Service, Finance, and Provider Networks.

You will guide care delivery operations, ensure cost control, monitor provider performance, and coordinate across departments to maintain seamless processes that support Flexicare

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 (CS) medical concerns and escalations
• Review and evaluate contracts (providers)
• Screen, accredit, and onboard CCM and clinic management doctors
• Monitor PROs’ KRAs and overall performance
• Initiate and support NetSuite PRT module upgrades (medical validation and process alignment)
• Attend to medical needs of Flexicare employees
• Provide real-time medical guidance to CSRs
• Analyze utilization data and provide strategic recommendations to management
• Diagnose and adjudicate claims to ensure accuracy and cost control
• Ensure coordination across departments and business units for seamless operations

Job description

RelianceUnited in Manila seeks a senior health operations leader to provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation, and internal medical support, acting as a vital bridge between Clinical, Customer Service, Finance, and Provider Networks.

You will guide care delivery operations, ensure cost control, monitor provider performance, and coordinate across departments to maintain seamless processes that support Flexicare