UTILIZATION SPECIALIST (MAKATI, PHILIPPINES)

Inova Care; Makati; On-site; PHP 300,000 - 600,000; Full time

Job summary

Inova Care is seeking a healthcare professional to support high-quality utilization management and care coordination services in the Philippines. You will evaluate medical necessity, determine coverage, and coordinate with patients, providers, claims, and product teams to promote timely, appropriate care.

The role involves conducting reviews, providing prior authorizations, and developing individualized care plans while maintaining accurate digital records.

Qualifications

• Registered healthcare professional with relevant clinical experience in utilization management.
• Strong knowledge of medical necessity review and clinical appropriateness.
• Experience reviewing inpatient and outpatient services, authorizations, and discharge requirements.
• Ability to apply clinical pathways, client requirements, benefit rules, and policies consistently.
• Strong analytical and problem-solving skills.
• Clear written and verbal communication with patients, families, providers, and internal teams.
• Empathetic patient support and service-oriented care coordination.
• High attention to detail and good record-keeping using digital health systems.
• Ability to manage multiple cases and meet service level requirements while maintaining confidentiality.
• Proficiency in standard office and digital collaboration tools.

Responsibilities

• Conduct authorization reviews for outpatient, inpatient, emergency, elective, non-elective, dental, and health screening procedures.
• Provide prior authorization and authorization support for inpatient admissions, selected treatments, and providers requiring approval before services are delivered.
• Evaluate authorization, concurrent, and retrospective reviews using international clinical pathways and applicable client requirements.
• Determine medical necessity, medical appropriateness, benefit liability, member eligibility, waiting periods, pre-existing conditions, exclusions, and coverage for healthcare and dental claims.
• Conduct concurrent reviews, case monitoring, discharge planning, and coordination of care for inpatient admissions.
• Issue final guarantee letters to hospitals outlining payment responsibilities before member discharge.
• Conduct detailed remote patient assessments, monitor health conditions, and coordinate findings with healthcare providers.
• Develop and implement individualized care and monitoring plans, including education on chronic condition management and preventive care.
• Provide support and guidance to patients and their families throughout the healthcare journey.
• Maintain complete, accurate, and up-to-date patient and case records in digital platforms.
• Work collaboratively with healthcare professionals to support continuity and comprehensive delivery of care.
• Provide input to claims and customer care teams regarding medical necessity, medical appropriateness, benefit clarification, and claim status.
• Collaborate with claims teams on fraud and abuse detection programs.
• Partner with provider relations and provider networks to promote compliance with international clinical pathways and locally adapted business rules.
• Complete case reviews within required turnaround times and service level requirements.
• Contribute utilization management insights to product development and senior management to support new products, service improvements, and optimized claim expenses.
• Ensure utilization management programs are properly documented and aligned with approved clinical pathways.
• Participate in the development and quality improvement of remote monitoring programs.
• Perform other duties supporting utilization management and business objectives.

Skills

Clinical experience

Utilization management

Care coordination

Claims review

Case management

Medical documentation

Job description

About the role

Support the delivery of high-quality utilization management and care coordination services by evaluating medical necessity, medical appropriateness, benefit coverage, and member eligibility. The role works closely with patients, healthcare providers, claims, customer care, provider relations, and product teams to promote appropriate care, effective treatment planning, timely decisions, and positive member outcomes.

Key responsibilities

• Conduct authorization reviews for outpatient, inpatient, emergency, elective, non-elective, dental, and health screening procedures.


• Provide prior authorization and authorization support for inpatient admissions, selected treatments, and providers requiring approval before services are delivered.


• Evaluate authorization, concurrent, and retrospective reviews using international clinical pathways and applicable client requirements.


• Determine medical necessity, medical appropriateness, benefit liability, member eligibility, waiting periods, pre-existing conditions, exclusions, and coverage for healthcare and dental claims.


• Conduct concurrent reviews, case monitoring, discharge planning, and coordination of care for inpatient admissions.


• Issue final guarantee letters to hospitals outlining payment responsibilities before member discharge.


• Conduct detailed remote patient assessments, monitor health conditions, and coordinate findings with healthcare providers.


• Develop and implement individualized care and monitoring plans, including education on chronic condition management and preventive care.


• Provide support and guidance to patients and their families throughout the healthcare journey.


• Maintain complete, accurate, and up-to-date patient and case records in digital platforms.


• Work collaboratively with healthcare professionals to support continuity and comprehensive delivery of care.


• Provide input to claims and customer care teams regarding medical necessity, medical appropriateness, benefit clarification, and claim status.


• Collaborate with claims teams on fraud and abuse detection programs.


• Partner with provider relations and provider networks to promote compliance with international clinical pathways and locally adapted business rules.


• Complete case reviews within required turnaround times and service level requirements.


• Contribute utilization management insights to product development and senior management to support new products, service improvements, and optimized claim expenses.


• Ensure utilization management programs are properly documented and aligned with approved clinical pathways.


• Participate in the development and quality improvement of remote monitoring programs.


• Perform other duties supporting utilization management and business objectives.

What we're looking for

• Registered healthcare professional with relevant clinical experience in utilization management, claims review, care coordination, case management, or a related healthcare setting.


• Strong knowledge of medical necessity review, clinical appropriateness, benefit interpretation, and healthcare documentation.


• Experience reviewing inpatient and outpatient services, treatment plans, authorizations, and discharge requirements.


• Ability to apply clinical pathways, client requirements, benefit rules, and regulatory or organizational policies consistently.


• Strong assessment, analytical, decision-making, and problem-solving skills.


• Clear written and verbal communication skills with the ability to work effectively with patients, families, providers, and internal teams.


• Empathetic patient support skills and a service-oriented approach to care coordination.


• High attention to detail and strong record-keeping skills using digital platforms and healthcare information systems.


• Ability to manage multiple cases, meet service level requirements, and maintain confidentiality of patient information.


• Proficiency in standard office and digital collaboration tools.