Insurance Utilization Review Jobs in Washington (NOW HIRING)

ZemiTek, LLC is a Woman-Owned, SBA-certified 8(a) Small Disadvantaged Business (SDB) based in the Washington, DC metro area. We have a strong record delivering innovative and high-quality solutions. Since 2007, ZemiTek has provided technical assistance, project management, information technology (IT), knowledge management, monitoring and evaluation, training and learning development, and institutional support services.

Global Solutions Ventures (GSV) – a joint-venture partnership between ZemiTek, LLC and Dexis Consulting Group – is implementing the Long-term Exceptional Technical Assistance Project (LEAP Global), a mechanism originally used by USAID to battle against infectious diseases such as malaria, HIV/AIDS, tuberculosis, neglected tropical diseases, and pandemic influenza. As of July 1, 2025, LEAP Global transitioned to the U.S. Department of State (DOS). This initiative aims to address the complex human resource challenges faced by national infectious disease programs in the USA-supported countries.

The intervention of this project is to hire and embed technical expert advisors and subject matter experts within government entities. By directly embedding the technical expertise within the national programs, LEAP provides long-term, sustainable lifesaving support to empower host governments to lead and manage key aspects of their infectious disease portfolios and improve coordination between the U.S. Government and the host country.

The TB Benefit and Membership Integration Advisor – PhilHealth will support the Philippine Health Insurance Corporation (PhilHealth) in strengthening the end-to-end membership journey, with a focus on translating membership into effective access, navigation, and utilization of health services particularly for TB clients who are eligible to avail of the PhilHealth TB DOTS package.

While PhilHealth has made significant progress in expanding coverage, key gaps remain in ensuring that members are able to seamlessly access and utilize benefits across the continuum of care. These challenges include fragmented service delivery pathways, limited visibility of patient movement across systems, and inefficiencies in provider workflows and claims processes.

Anchored within the Member Management Group (MMG), the Advisor will focus on bridging membership platforms with service delivery, provider engagement, and benefit utilization, ensuring that membership results in actual service use and improved health outcomes.  The Advisor will support the Department of Health in carrying out life-saving humanitarian assistance (LHA) service delivery in full alignment with the new Presidential Executive Order (EO) directives. 

The engagement will use the TB DOTS benefit package as a tracer program to:

• Map and analyze the full membership-to-care journey
• Identify systemic bottlenecks affecting access and utilization
• Design and test solutions that can be scaled across other benefit packages and conditions

Embedded within PhilHealth and working closely with MMG, Operations, IMS, and other relevant units, the Advisor will support a delivery-oriented, iterative process to strengthen systems, policies, and digital tools that enable effective member access and utilization.

Work Location: Philippines

The TB Benefit and Membership Integration Advisor will:

• Conduct a rapid desk review of existing PhilHealth policies, circulars, guidelines, and technical reports related to membership, primary care (YAKAP), and selected benefit packages.
• Review available data on membership, service utilization, and claims patterns.
• Map existing systems and processes that support the membership journey and service delivery.
• Develop a detailed work plan, including priority workstreams, timelines, and key milestones.
• Agree with PhilHealth on governance arrangements, coordination mechanisms, and validation processes.

• Map the end-to-end membership journey, including:
• Registration to the NHIP
• Assignment/empanelment to providers under YAKAP
• First Patient Encounter (FPE) and initial service access
• Navigation across services (diagnosis, treatment, follow-up)
• Claims processing and benefit utilization
• Use TB DOTS as a tracer condition to ground the analysis in a real-world care pathway.
• Identify key friction points, drop-offs, and inefficiencies affecting member access and continuity of care.
• Assess how digital tools and systems support or hinder this journey.

• Analyze data across membership, service delivery, and claims to understand:
• Conversion from membership to actual utilization
• Drop-offs across the care continuum
• Variations in performance across regions, providers, and member segments
• Use TB DOTS data to generate deeper insights into patient pathways and outcomes.
• Support development of dashboards or tracking tools to monitor membership-to-utilization performance.

• Facilitate consultations with:
• PhilHealth units (MMG, Operations, IMS, FMS, Corporate Planning)
• Selected providers and field units (PROs/LHIOs)
• Development partners and technical stakeholders
• Validate findings and co-develop solutions with implementers.
• Document agreements, action points, and recommendations.

• Co-develop solutions to strengthen the membership-to-care continuum, including:
• Improving navigation from enrollment to service access
• Enhancing provider engagement and accountability
• Strengthening continuity of care within empaneled providers
• Use TB DOTS as a testing ground for interventions, such as:
• Integration of screening and care pathways within FPE
• Strengthening referral and follow-up systems
• Ensure alignment with YAKAP design, including empanelment, primary care delivery, and capitation.

• Assess and recommend enhancements to digital platforms and systems, including:
• Member-facing tools (e.g., portals, navigation support)
• Provider systems (reporting, service tracking)
• Claims processing platforms
• Identify opportunities for:
• Improved interoperability and data exchange
• Automation of workflows
• Real-time tracking of member journeys and service utilization
• Work with relevant PhilHealth units to align digital enhancements with broader system modernization efforts.

• Draft or revise policy issuances to strengthen:
• Membership-to-utilization linkages
• Service delivery integration
• Claims and provider processes
• Prepare technical briefs, presentations, and decision materials for senior management.
• Support internal alignment and decision-making processes.
• Ensure that reforms are documented and institutionalized.

• Support rollout of priority interventions, including pilot testing where appropriate.
• Track key indicators related to:
• Member access and navigation
• Service utilization
• Continuity of care
• Provide regular updates and recommend course corrections.

• Perform such other tasks as may be necessary or incidental to the achievement of the objectives of the engagement, as may be assigned by PhilHealth.

• Inception Report (Workplan and Initial Assessment)
• Implementation Updates and Progress Reports
• Membership and Benefit Availment Journey for TB Mapping Report 
• Analytics and Utilization Brief
• Digital Systems and Process Enhancement Brief
• Policy and Systems Recommendations including draft issues e.g. PhilHealth Circulars, Corporate Orders on TB DOTS and YAKAP enhancement, etc
• Final Report and Executive Presentation

The Advisor will provide a detailed monthly report to the U.S. Department of State submitted by the 5th day of the following month. The Advisor will submit a weekly progress report to U.S. Embassy/Department of State (and participate in weekly calls) to include a short paragraph about main successes for that week. Additionally, 

• Report directly to the Member Management Group (MMG) or designated Project Lead
• Provide regular progress reports
• Participate in coordination meetings with relevant units
• Support preparation of materials for senior management as required

• Advanced degree in public health, medicine, health economics, or related field
• At least 7–10 years of experience in:
• Health systems strengthening
• Health financing or insurance systems
• Service delivery and/or primary care systems
• Strong background in:
• Data analytics and systems thinking
• Policy development and implementation
• Experience working with government and multi-stakeholder environments
• Excellent communication and analytical skills
• Excellent written and oral communication skills in English and Filipino

• Experience working with PhilHealth or similar national health insurance systems
• Familiarity with Universal Health Care reforms and primary care models
• Experience with development partner–supported programs
• Experience in embedded advisory or delivery-unit models

ZemiTek is committed to the full inclusion of all qualified individuals. As part of this commitment, ZemiTek will ensure that persons with disabilities are provided reasonable accommodations. If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to accommodations@zemitek.com.