QLM Insurance
The Network Manager’s role is to establish and negotiate competitive agreement terms with the medical network providers. He will work with the provider management team in order to develop the network of providers, enhance the service delivery, negotiate reasonable terms with providers and ensure that providers adhere to the SLAs and corporate guidelines.
The position will be reporting to the Chief Medical Officer, the ideal candidate should be an experienced health/medical professional with a strong exposure towards TPA management, and can demonstrate solid negotiation skills, this position is catered to bilingual candidates only (Arabic & English).
Key Responsibilities:
• Develop and expand Medical Network to meet ever-growing customers’ needs and demands.
• Ensure all signed agreements adhere to local regulatory and Corporate outsourcing guidelines and requirements.
• Maintain relationships with key hospitals, in-house panel Medical Providers and appointed TPAs.
• Ensure Letter of Guarantee (LOG) processes are adhered to by the providers.
• Negotiate with potential Medical Specialists for cashless-facility and preferential outpatient, inpatient and surgical fees.
• Conduct annual due diligence assessments on appointed TPAs according to local regulatory guidelines and requirements.
• Monitor and ensure business efficiency and appointed TPAs’ Service Level Agreements (SLAs) are met.
• Provide complaints resolution in relation to service delivery failure, claims, payment matters with Medical Providers, TPAs etc.
• Analyze hospitals and panel Specialists’ utilization data to develop appropriate strategic measures to manage and contain escalating medical costs.
• Serves as a communication link between professional providers and the company.
• Ensure that network composition includes an appropriate distribution of provider specialties.
• Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations.
• Perform periodic analyses of the provider network from a cost, coverage, and growth perspective. Provide leadership in evaluating opportunities to expand or change the network to meet Plan goals.
• Evaluate the provider network and implement strategic plans to achieve organizational targets and financial objectives through effective primary care, specialty, hospital and ancillary provider contracting and contract management.
• Strategically aligns resources by continuously planning and organizing to meet initiatives.
• Establish quality control mechanisms for processes and continuously strive to improve operational efficiency through process redesign and data driven evaluation of performance.
• Collaborate on and coordinate activities with other departments in the Health Plan and other divisions to support the network and the members it serves.
• Ensure provider education (new provider orientation, provider education/seminars, ongoing visits, meetings, provider manuals/bulletins/newsletters, etc.) activities are done in a timely and cost-effective manner to continuously improve relationships with network providers and the delivery of care to our membership.
• Conduct an annual effectiveness review of all provider satisfaction initiatives.
• Work with all the stakeholders to develop future strategic plans for all areas of Network Management.
Qualifications and Experience:
• 3-5 years of experience in a Provider Contracting role in a TPA / medical insurance company preferably in the Gulf region.
• Bachelor degree or Diploma in Medicine, Physiotherapy, Nursing, Radiology, Laboratory technician or Hospital Administration.
• Excellent interpersonal skills and ability to communicate clearly and effectively with internal and external clients across all levels, with fluency in business English (written and spoken); and Arabic.
• High technical skill in Microsoft Suite programs (Word, Excel, Powerpoint)
• Experience of working in a regulated entity highly preferred
• Proven ability to manage work flows effectively in a multi-stakeholder environment
• Industry knowledge related to local healthcare services system will be an added advantage.