• Reviews and analyzes medical information and provides oversight in reviewing, evaluating and determining the medical necessity of service treatment request to ensure that treatments are consistent with patient’s diagnosis, treatment plans, coverage guidelines and policies.
• Determines appropriateness of services based on consistent application of decision support and effective delivery system and takes responsibility in communicating to providers and patients in a timely and effective manner.
• Reviews financial and utilization data and prepares a comparative analysis of actual and benchmark/goals. Develops and recommends initiatives, strategies and programs in developing improvement action plans as appropriate.
• Performs telephonic and/or onsite review of concurrent patient services and retrospective quality of care issues, access and outcome studies i.e., HEDIS, NCQA.
• 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.
• Develops and maintains quality assurance measures to ensure consistency in application of decisions on requests for health care services, utilizing evidenced-based guidelines and criteria and decision support systems.
• 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.
• 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.
• Provides feedback to physicians, providers, facilities and members regarding coordination and authorization process and treatment plan.
• Provides oversight of Case Management Program to proactively identify and refer catastrophically and chronically ill patients to case management using established criteria.
• Assist in developing industry recognized benchmarks for program tracking of caseloads, cost savings,and utilization.
• Coordinates and manages relationship with third parties to ensure timely and cost-effective services are delivered and routed to the appropriate health care delivery systems.
• Collaborates and reviews on-going cases with reinsurance partners to manage risks and costs.
• Collaborates and reviews potential high dollar cases to ensure that appropriate treatments are provided at cost effective delivery systems.

• Evaluates and reviews staffing requirements and responsible for scheduling to ensure adequate department coverage.
• Evaluates staff performance and conducts reviews according to company guidelines and protocol.
• Supervise daily department activities to ensure completion of deliverables based on established benchmarks and goals.
• Monitors team performance and develops streamlined and efficient processes through workflow improvement and process re-engineering.
• Coordinates and liaison with the Health Plan Administrator, Medicare Director and/or Peer Reviewer to ensure utilization strategies and initiatives are developed and implemented to support overall cost effectiveness and health care quality is achieved consistent with company’s goals and objectives.
• Monitors and trouble shoot moderate to complex department issues in collaboration with the Health Plan Administrator and/or Medical Director
• Organizes and implements a regular communication session with 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.
• Conducts departmental staff development and enrichment training as needed keeping individual goals aligned with department and organizational goals and objectives.

1. Graduate of Bachelor’s Degree in Nursing or other related field; License required.
2. Minimum of 3 years (supervisory) or 5 years (managerial) experience with impressive track record in performing routine to complex utilization management activities and strategies relating to coordination, concurrent review, discharge planning, prior authorization, case management and retrospective reviews to ensure effective and efficient provision of quality and appropriate health care services
3. Minimum of 3 years management experience.
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 behavioral sensitivity, maturity, diplomacy and tact to address 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 of federal and state laws and requirements relating to healthcare management.
9. Computer literate and very highly proficient in using MS office programs.

• Provides direct medical services to patients in Family Practice /Adult Medicine for patients in ambulatory, and inpatient settings.
• Serves as an advisor to the Medical Director in the development of programs and services, improvement of services and in troubleshooting problems at the FHP Health Center.
• Participates in the overall clinical management of patients seen in Family Practice, Urgent Care, Preventive Care and Diabetes clinics. As well as assists in the overall leadership of the clinical services with other staff providers in various activities including but not limited to: written clinical protocols, managed care and preventative health guidelines.
• Prescribes or administer treatment, therapy, medication, vaccination and other specialized medical care to treat or prevent illness, disease or injury.
• Order, perform and interpret test and analyze records, reports and examination information to diagnose patients’ condition.
• Collect, record and maintain patient information such as medical history, reports and examination results.
• Monitor patients’ conditions and progress and re-evaluation treatments as necessary
• Explain procedures and discuss test results or prescribed treatments with patients.
• Advise patients and community members concerning diet, activity, hygiene and disease prevention.
• Refer patients to medical specialists or other practitioners when necessary.
• Works with underserved and underinsured diverse populations.

1. Graduate of Doctor of Medicine. Guam license is required
2. Must be US Board Certified or US Board Eligible
3. Must have completed Residency and/or Fellowship in the US and passed the US qualifying exam (USMLE or FLEX).
4. Must be eligible to work in the US.
5. Minimum of 3 years experience in planning and carrying out medical care program
6. Must have the appropriate level of behavioral maturity and patience in handling patients.
7. Must have the diplomacy and tact in handling difficult and irate patients.
8. Very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
9. Outstanding communication skills and persuasiveness, ability to communicate instructions and procedures for treatments, keeping the patients and giving them the desired level of comfort and confidence.
10. Must have strong sensitivity to the needs and anxieties of patients and the ability to motivate patients to undergo treatments and procedures.
11. Strong ethics and a high level of personal and professional integrity.
12. Knowledgeable of federal and state laws and requirements relating to healthcare management.

Location: Manila, Metro Manila, Philippines

Job Summary:

Reports directly to the Utilization Management Team Lead and responsible for reviewing treatment plans and services that are already underway in order to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources. Also, evaluates the quality of care and its conformance with organizational policies, procedures and guidelines, as well as compliance with government regulations.

Duties and Responsibilities

1. Medical Referral

1. Inputs and processes authorization requests and authorizations per guidelines and according to defined time and accuracy standards.
2. Reviews the health plan and other guidelines to ensure that services being provided to eligible members are within the scope of the benefit plan and contracted providers are being utilized.
3. Issues letters of authorization and applies appropriate contracted or negotiated rates using established criteria.
4. Provides members with verification of eligibility, interpretation of benefits, and appropriate contracted provider/facility.
5. Screens and troubleshoots calls or walk-in’s regarding member care within scope of position. Routes members and provider concerns outside that scope to appropriate department or co-employees.
6. Maintains effective communication with members, providers, and other TakeCare staff to ensure adherence to company policies, guidelines and processes.
7. Corresponds with TakeCare Guam for coordination of members’ off-island referrals.
8. Administers reports and maintains files of correspondence, medical records, and other documentation, as appropriate, to report status and to support workflow.

2. Medical Review/Medical Management

1. Supports the Medical Review Specialist II, Medical Review Supervisor and other members of the Medical Review/Medical Management Team in the review and analysis of medical information in order to determine the medical necessity of continued stay according to review standards.
2. Works with the Medical Review/Medical Management Team to determine medical necessity and length of stay based on the consistent application of decision support system and communicates decisions to providers and patients.
3. Works with the Medical Review/Medical Management Team in the coordination of discharge planning with physicians, members, families, caregivers and ancillary providers to support the member’s continuity of care needs.
4. Provides reports on quality-of-care issues. Submits reports and communicates in a timely and effective manner to the Manager of the Medical Referral Office.
5. Performs telephonic and onsite review of concurrent patient services and retrospective quality care issues, access, and outcome studies.
6. Maintains ongoing database/documentation to monitor all activities/treatment and outcome plans for patients’ conformance with organizational and government regulations.
7. Ensures that services provided to eligible members are within the benefit plan and appropriate contracted providers are being utilized.
8. Coordinates out of area cases ensuring patient receives cost-effective quality care and monitor patient for return to work.
9. Performs other duties that may be assigned from time to time.

Job Specifications

1. Graduate of Bachelor’s Degree – RN License is required.
2. Minimum of 2 years experience and must have impressive track record in reviewing treatment plans and services to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources.
3. Effective team player.
4. Excellent interpersonal skills.
5. Must have 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 government rules and regulations relating to healthcare management.
9. Proficient in using MS Office programs.

Location: Tamuning, Guam

Job Summary:

Reports directly the HCD Administrator. Responsible for examining patients to obtain information about their physical condition, interpreting diagnostic test results for deviations from normal and making diagnoses and decisions about management and treatment of patients.

Essential Duties and Responsibilities:

• Provide clinical services and management of pediatric, adolescent and adult patients as defined in the standing orders, policies, procedures and standard of care.
• Obtain patient health histories and complete physical examinations.
• Document findings noting pertinent normal and abnormal findings.
• Order and interpret appropriate diagnostic and laboratory tests.
• Obtain, compile and record patient medical data, including health history, progress notes and results of physical examination.
• Administer or order diagnostic tests, such as x-ray, electrocardiogram, and laboratory tests.
• Prescribe therapy or medication and perform approved therapeutic procedures based upon patient's clinical status.
• Perform therapeutic procedures, such as injections, immunizations, suturing and wound care, and infection management.
• Instruct and counsel patients about prescribed therapeutic regimens, normal growth and development, family planning, emotional problems of daily living, and health maintenance.
• Explain the necessity, preparation, nature and anticipated effects of procedure(s) to patient, family, staff, and healthcare learners.
• Collaborate with physician and nursing colleagues and document in medical records and appropriate narrative summaries.
• Document all prescriptions in patient's medical record.
• Initiate necessary emergency interventions to stabilize patient.
• Utilize current research and evidence-based decision-making in all clinical practice.
• Incorporate clinical research findings in the development and implementation of standards of care.
• Perform and participate in quality/performance improvement activities.
• Serve as an expert consultant to nursing, members of the healthcare team and to the larger community.
• Participate in and support accreditation, compliance, and regulatory activities of the organization.
• Models professional healthcare provider through conduct, appearance, communication, mutual respect, leadership, ethical decision-making, critical thinking, and problem-solving skills.
• Demonstrate responsibility for professional practice through active participation in professional organizations and continuing education.
• Enhance the body of knowledge of medicine or area of specialization through continuing education, exchange of ideas and knowledge in professional organizations, oral presentations, posters, research activities, and written publications.
• Perform other related duties that may be assigned from time to time.

Education & Experience:

1. Graduate of Physician Assistant in an accredited PA program. License is required.
2. BLS and ACLS certification required. PALS certification encouraged.
3. Must have the appropriate level of behavioral maturity and patience in handling patients.
4. Must have the diplomacy and tact in handling difficult and irate patients.
5. Very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
6. Outstanding communication skills and persuasiveness, specially the ability to communicate instructions and procedures for treatments, keeping the patients and giving them the desired level of comfort and confidence.
7. Must have strong sensitivity to the needs and anxieties of patients and the ability to motivate patients to undergo treatments and procedures.
8. Strong ethics and a high level of personal and professional integrity.
9. Knowledgeable of federal and state laws and requirements relating to healthcare management.

Location: Tamuning, Guam

Job Summary:

Reports directly to the Health Care Delivery (HCD) Administrator at assigned department and responsible for examining patients to obtain information about their physical condition, interpreting diagnostic test results for deviations from normal and making tentative diagnoses and decisions about management and treatment of patients.

Essential Duties and Responsibilities:

• Provide direct clinical services and management of pediatric, adolescent and adult patients as defined in the standing orders, policies, procedures and guidelines for the certified nurse practitioner.
• Obtain patient health histories and complete physical examinations.
• Document findings noting pertinent normal and abnormal findings.
• Obtain, compile and record patient medical data, including health history, progress notes and results of physical examination.
• Administer or order diagnostic tests, such as x-ray, electrocardiogram, and laboratory tests.
• Prescribe therapy or medication with physician’s approval.
• Perform therapeutic procedures, such as injections, immunizations, suturing and wound care, and infection management.
• Instruct and counsel patients about prescribed therapeutic regimens, normal growth and development, family planning, emotional problems of daily living, and health maintenance.
• Obtain patient health histories and complete physical examinations.
• Document findings noting pertinent normal and abnormal findings.
• Order and interpret appropriate diagnostic and laboratory tests.
• Explain the necessity, preparation, nature and anticipated effects of procedure(s) to patient, family, staff, and healthcare learners.
• Perform approved therapeutic procedures based upon patient's clinical status.
• Collaborate with physician and nursing colleagues and document in medical records and appropriate narrative summaries.
• Utilize prescriptive privileges as allowed by the Guam Board of Nurse Examiner
• Document all prescriptions in patient's medical record.
• Assess patient for deviations from normal and institute appropriate interventions.
• Initiate necessary emergency interventions to stabilize patient.
• Utilize current research and evidence-based decision-making in all clinical practice.
• Incorporate clinical research findings in the development and implementation of standards of care.
• Perform and participate in quality/performance improvement activities.
• Serve as an expert consultant to nursing, members of the healthcare team and to the larger community.
• Participate in and support accreditation, compliance, and regulatory activities of the organization.
• Model advanced practice professional nursing through conduct, appearance, communication, mutual respect, leadership, ethical decision-making, critical thinking, and problem-solving skills.
• Demonstrate responsibility for professional practice through active participation in professional organizations and continuing education.
• Enhance the body of knowledge of nursing or area of specialization through exchange of ideas and knowledge in professional organizations, oral presentations, posters, research activities, and written publications.
• Perform other related duties that may be assigned from time to time.

Education & Experience:

1. Graduate of Family Nurse Practitioner program. License is required.
2. Current BLS and CPR Certification.
3. Experience serving a multinational, multiracial population.
4. Must have the appropriate level of behavioral maturity and patience in handling patients.
5. Must have the diplomacy and tact in handling difficult and irate patients.
6. Very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
7. Outstanding communication skills and persuasiveness, specially the ability to communicate instructions and procedures for treatments, keeping the patients and giving them the desired level of comfort and confidence.
8. Must have strong sensitivity to the needs and anxieties of patients and the ability to motivate patients to undergo treatments and procedures.
9. Strong ethics and a high level of personal and professional integrity.
10. Knowledgeable of federal and state laws and requirements relating to healthcare management.