Education and Experience:

1.      Graduate of Bachelor’s Degree in Nursing or other related field; License required.

2.      Minimum of 10 years experience with impressive track record in performing basic to routine medical management activities related to authorization of treatment requests to ensure efficient use of patient utilization systems, and quality care using appropriate medical resources.

3.      Supervisory and management experience preferred.

4.      Effective team player. With very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.

5.      Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.

6.      Outstanding oral and written communication skills.

7.      Strong ethics and a high level of personal and professional integrity.

8.      Must have basic familiarity on federal and state laws and requirements relating to healthcare management.

9.      Computer literate and very highly proficient in using MS office programs.

Essential Duties and Responsibilities:

Utilization Management:

1.      Reviews and analyzes medical information and provides assistance in reviewing, evaluating and determining the medical necessity of service treatment request to ensure that treatments are consistent with patient’s diagnosis.

2.      Determines appropriateness of services based on consistent application of decision support system and takes responsibility in communicating this to providers and patients in a timely and effective manner.

3.      Reviews financial and utilization data and prepares an analysis of comparison versus benchmark data. Develops and recommends initiatives and programs in developing improvement action plans as appropriate.

4.      Performs telephonic and/or onsite review of basic to routine concurrent patient services and retrospective quality of care issues, access and outcome studies i.e., HEDIS, NCQA.

5.      Maintains ongoing database/documentation to monitor all activities/treatment and outcome plans for patients. This should be in conformance with organizational policies and guidelines and compliant with government regulations.

6.      Develops and maintains quality assurance measures to ensure consistency in the applying decisions on requests for medical services, utilizing evidenced-based guidelines and criteria and decision support systems.

7.      Develops and implements tracking and control procedures to ensure that services being provided to eligible members are within the scope of the benefit plan and contracted providers are being utilized.

8.      Oversees the coordination and concurrent review of patients to ensure services are provided at the appropriate level of care utilizing evidence-based guidelines and criteria in the review and decision process.

9.      Provides feedback to physicians, providers, facilities and members regarding authorization process and treatment plan.

10.   Provides oversight on Case Management Program to proactively identify and refer catastrophically and chronically ill patients to case management using established criteria.

11.   Oversees provider network development for the Philippines to include hospital facilities, clinic and/or physician-specialist.

12.   Assist in developing industry recognized benchmarks for program tracking of caseloads, cost savings, and utilization.

Management:

1.      Evaluates staffing needs and responsible for scheduling to ensure adequate department coverage. 

2.      Evaluates staff performance and conducts reviews according to company guidelines and protocol.

3.      Supervise daily department activities to ensure completion of deliverables based on established benchmarks.

4.      Establish departmental goals and metrics and ensure necessary tracking are in place to achieve or exceed these goals including formulation of action plans to address any deficiencies.

5.      Monitors team performance and develops streamlined processes through an improved work flow.

6.      Monitors and trouble shoots moderate to complex department issues in collaboration with the Medical Management Manager.

7.      Organizes and implements a regular communication session with Health Plan Administrator, Medical or Associate Medical Director, Medical Management Staff, and other health care team members, and provides a venue whereby issues and concerns are discussed in a timely and effective manner.

8.      Conducts departmental staff development and enrichment training as needed keeping individual goals aligned with department and organizational goals and objectives.

Job Summary:

Reports directly to the Health Plan Administrator and responsible for performing complex medical management activities related to authorization of treatment requests to ensure efficient use of patient utilization systems, and quality care using appropriate medical resources. 

Also responsible for providing assistance in evaluating the quality of medical care and utilization, and ensures conformance with organizational policies and guidelines and compliance with government regulations. Supervises and monitors daily utilization activities in the department, tracks and evaluates staff performance related to utilization review, processing, approval, and denials.