A well-established company is recruiting for a
SPECIALIST NETWORK PROVIDER MANAGEMENT
BRYANSTON
Purpose of the role:
The Specialist: Network provider management will be responsible for establishing, implementing, managing, and monitoring a network of suitable health providers for CAMAF within the Managed Care strategy. This role involves liaising with healthcare providers, negotiating terms, building relationships, and ensuring that the network is effective and efficient. Accountable for the provision of specialist knowledge, delivery plans and associated practices to minimise the Scheme's financial risk by developing and maintaining key relationships with health provider networks.
Key Responsibilities
Provider Relations and Network Development:
- Identify, approach, and engage with potential medical service providers (specialists) to build a network.
- Lead provider network management projects.
- Recruit and negotiate contracts with providers with Scheme mandate.
- Facilitate annual tariff negotiations within Scheme mandate.
- Establish strong relationships with existing and new healthcare providers to ensure continuous network retention and growth.
- Ensuring the network provider list is maintained and available to members.
- Establish rates, and conditions with providers, ensuring alignment with the scheme's policies.
- Coordinate and conduct regular meetings with medical providers to ensure service delivery standards are met.
- Ensure completed and signed agreements with the network providers.
- Ensure effective communication throughout the project lifecycle.
Network Analysis and Strategy:
- Identify gaps in our current network arrangement and develop a comprehensive plan to mitigate and close these gaps.
- Align network development with our Managed Care strategy.
- Implement, manage, and monitor the return on investments for recommended and approved networks.
Claims Monitoring and Risk Management:
- Monitor claims submitted by network providers to ensure they comply with the scheme's rates and are accurately processed.
- Monitor provider performance standards, including claims loss ratio.
- Work with the claims department to ensure timely resolution of issues related to claims, payments, and provider disputes.
- Ensure providers submit accurate claims according to the agreed-upon terms.
- Oversee negotiated tariffs as per our approved Scheme mandate.
- Investigate any discrepancies or issues in claims, working directly with providers and internal teams to resolve them.
- Implement sound governance and compliance processes.
- Support internal and external audits.
- Contribute to annual budget planning and implementation.
Network Performance Monitoring and Reporting:
- Monitor the performance of the provider network, tracking key metrics such as claim volumes, approval rates, and provider satisfaction.
- Provide regular feedback and reports to management on the network's performance and any issues arising from provider interactions.
- Identify areas for improvement in the network and propose solutions to enhance efficiency and service delivery.
- Resolve provider-related issues and provide ongoing education.
Compliance and Quality Assurance:
- Ensure that all providers in the network comply with the medical scheme's rates, protocols, and industry regulations.
- Stay informed about changes in healthcare regulations and industry best practices to ensure the network remains compliant.
- Regularly audit provider records and claims to ensure adherence to scheme rules and quality standards.
Customer Service and Issue Resolution:
- Act as the primary point of contact for providers in the network regarding any queries or issues.
- Address provider complaints or concerns in a professional and timely manner.
- Collaborate with the customer service team to ensure smooth provider interactions and resolve any patient or provider-related issues.
Training and Development:
- Provide training to new and existing network providers on medical scheme rates, claim procedures, and service standards.
- Keep providers informed of any updates or changes in the scheme's requirements or protocols.
This role requires a highly organised individual with strong healthcare industry knowledge and excellent relationship-building skills. The Specialist Network Coordinator will be integral to ensuring the success of the medical scheme's provider network, which ultimately impacts the cost and quality of service provided to its members.
Requirements:
- NQF level 5 Degree or Diploma
- 1 to 2 years in the healthcare industry
- Proven experience in Provider Network Management
- Strong project management skills
Please send your cv and supporting to [Email Address Removed].
If you have not received any feedback within 2 weeks please assume that your application was not successful
