Job Description

Customer Service

• Ensure that IHC members availing of medical services in accredited medical facilities are assisted accordingly.
• Ensure that members’ queries, concerns and/or complaints are attended to in a timely and appropriate manner prior to elevating this to the Medical Director.
• Keep abreast with current regulations and policies affecting medical services and implementation and provide proper guidance to all concerned.
• Be up to date on medical updates, utilization management, newly onboarded and renewed account benefits.
• Maintain company spiels and lines that will entice members to call them regarding their benefit including medical network inquiries, concerns and LOA issuances.
• Ensure that the member’s coverage and benefits is discussed appropriately and issue the letter of authorization (LOA).
• Assist the member during their availment by checking medical facility charges and professional fees to maximize member’s benefits and to prevent incurrence of excess charges beyond the benefit coverage and advises member on non-covered charges.
• Issue LOAs and assist members for MD scheduling of appointments and other services.
• Distribute service evaluation survey forms and ensure that the targeted confidence level and margin of error is met on a monthly basis.
• Receive comments, suggestions and feedback and collates survey results.

Utilization Management

• Ensure proper gatekeeping and utilization management through:
  • Determination of validity of the member status, benefit coverage and maximum available limit prior issuance of LOAs through information garnered from the Medical Account System (MAS).
  • Review of cases and checking necessity of availment and need for medical procedure.
  • Coordination of catastrophic cases to superior for case management.

Relationship Management

• Assist the Provider Management Division by:
  • Updating the records of physicians in coordination with Provider Accreditation and Relations team as the need arises.
  • Conducting initial claims for reimbursement screening submitted by members and inform members of any lacking documents, if any.
  • Monitor claims and inform members of acceptance/denial and release of checks