Functions
- The Medical Relations Associate is responsible for ensuring smooth coordination between members, healthcare providers, and internal departments for efficient delivery of HMO plan benefits. The role primarily focuses on handling requests related to Prior Authorizations and Letters of Authorization (LOAs) and facilitating medical availments in accordance with the member’s HMO coverage.
Duties and responsibilities :
- Assist and Request Handling, Receive and review members’ requests for Prior Authorization and LOA (Letter of Authorization) related to outpatient and inpatient services. Validate member eligibility and benefit coverage against the HMO plan. Communicate clearly with members regarding requirements, coverage limits, exclusions, and necessary documentation.
- LOA processing and Monitoring, Coordinate with the medical review team or affiliated physicians for approval of LOA requests, Ensure accurate and timely issuance of LOAs for covered services, Maintain records of all LOA requests and approvals, ensuring compliance with turnaround time standards, Follow up on pending or incomplete LOA requests and ensure proper documentation is submitted.
- Providers Coordination, Liaise with accredited healthcare providers (hospitals, clinics, diagnostic centers) to validate and process member availments, Coordinate with providers regarding services covered and not covered under HMO plans, Facilitate communication between providers and members when services are not covered, offering alternatives if available.
- Monitoring of Medical Availment, Track and monitor members’ medical availments for compliance with benefit limits and plan guidelines, Update system records to reflect utilization and pending requests, Assist in post-availment concerns, such as billing discrepancies or clarification of charges.
- Documentation and Reporting, Maintain accurate and up-to-date logs of all medical transactions, LOAs, and authorization requests, Prepare daily, weekly, or monthly reports as required by the Medical Relations or Utilization Review team, Identify and report recurring issues or process gaps that require attention or policy updates.
- Customer Service and Support, Provide prompt, courteous, and professional responses to member and provider inquiries, Educate members on the proper process of requesting authorizations and understanding their plan coverage, Escalate complex concerns to supervisors or the medical review team as appropriate.
- Other duties that can be assigned by immediate supervisor.
Requirements
- Must be a graduate BS Nursing with or without certification
- Knowledge of complex disease conditions, treatments, tests and medications
- Preferably with 1 to 3 years work experience in a health maintenance organization is a plus
- With decisive and analytical mind, Strong knowledge of HMO plan coverage and limitations, Excellent communication and interpersonal skills, Detail-oriented with strong organizational and follow-up skills, Ability to multitask and work in a fast-paced healthcare environment.
- Knowledgeable to MS Office applications and basic editing
- Must be customer-service oriented
- Must be willing to work on shifting schedule if needed
- Willing to work in Malate Manila & Makati City
- Candidate must be able to start ASAP