Job Description

MediCard Phils., Inc. is one of the country's leading HMO and the only HMO founded and run by Doctors. Since its inception, the concept of service-oriented total health care has been the molding ideal of MediCard. The competition is vast, and the benefits being offered by the competitors are tempting. However, MEDICard has taken the lead in providing innovative and productive ideas that cut down the cost of health maintenance without compromising its quality.

MediCard now boasts of more than half a million members and over 54,000 accredited doctors in over 1,000 hospitals and clinics nationwide. It also operates 16 MediCard free-standing clinics that provide services at par with those offered by hospitals minus the confinement.

MediCard is currently looking for assertive, dynamic and energetic individuals to fill up the following vacancy:

Lead and manage the Hospital Operations Services function to ensure the efficient implementation of healthcare benefits and delivery of high-quality medical services to members across accredited hospitals and healthcare facilities. Drive operational excellence by ensuring that inpatient and outpatient healthcare services are approved based on medical necessity,

evidence-based medicine, right treatment setting, right time, and benefit entitlement while balancing member satisfaction, quality outcomes, provider engagement, and cost containment.

The role ensures healthcare services are accessible, affordable, easy, predictable, and aligned with organizational objectives, regulatory requirements, and clinical governance standards.

DUTIES & RESPONSIBILITIES

1. Lead Hospital Operations Strategy and Performance (20%)

Develop and execute operational strategies, policies, and programs that support the organization's healthcare delivery objectives.

Establish service standards and operational performance metrics across all hospital operations functions

Monitor operational trends and recommend improvements to enhance member experience and organizational performance.

Lead strategic initiatives focused on healthcare accessibility, affordability, and quality outcomes.

1. Oversee Utilization Management and Medical Necessity Reviews (25%)

Ensure all inpatient, outpatient, emergency, and ancillary service approvals are evaluated based on medical necessity, evidence-based guidelines, benefit coverage, and appropriateness of care.

Direct pre-authorization, concurrent review, case management, and discharge planning activities.

Review high-cost and complex medical cases to ensure optimal treatment outcomes and resource utilization. Implement controls to reduce unnecessary admissions, procedures, diagnostics, and prolonged hospital stays.

1. Manage Hospital and Provider Relations (15%)

Develop and maintain strong partnerships with accredited hospitals, physicians, and healthcare providers.

Resolve escalated operational concerns affecting healthcare service delivery.

Collaborate with Provider Relations and Network Management teams to improve healthcare provider performance and service levels.

Participate in discussions related to hospital operational issues, healthcare trends, and service enhancements.

1. Drive Quality, Patient Safety and Clinical Governance (10%)

Ensure clinical decisions and authorization processes comply with evidence-based medicine and established clinical guidelines.

Monitor quality indicators and healthcare outcomes.

Lead medical audits, utilization reviews, and healthcare quality initiatives.

1. Ensure Excellence in Member Experience (10%)

Establish processes that improve healthcare access and simplify the member journey.

Monitor and improve turnaround times for approvals and healthcare service requests.

Address complex member concerns and high-impact service issues.

Ensure consistent delivery of accessible, affordable, easy, and predictable healthcare experiences.

1. Manage Financial Performance and Healthcare Costs (10%)

Monitor healthcare utilization trends, inpatient and outpatient expenditures, and medical cost drivers.

Develop initiatives that improve cost efficiency while maintaining quality care outcomes.

Support achievement of Medical Loss Ratio (MLR), healthcare utilization, and cost management targets.

Provide recommendations to optimize healthcare spending and resource utilization.

1. Lead and Develop Teams (10%)

Provide leadership, coaching, and performance management to Hospital Operations, Utilization Management, Case Management, and Medical Review teams.

Foster a culture of accountability, collaboration, service excellence, and continuous improvement.

Develop succession plans and talent development programs within the department.

At MediCard, we believe that diversity and inclusion are essential to fostering innovation, collaboration, and growth. We are committed to creating a workplace where everyone, regardless of gender, race, ethnicity, age, sexual orientation, disability, or any other characteristic, feels valued and empowered to contribute their unique perspectives and talents.

Our inclusive hiring practices ensure that we attract, hire, and retain the best talent from all backgrounds. We strive to provide equal opportunities for all candidates and promote a culture of respect, fairness, and transparency. We are dedicated to continuously improving our processes and policies to eliminate biases and barriers, ensuring that every employee has the support and resources they need to thrive.

MediCard is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Join MediCard Now!

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