Responsibility
- Developing integrated networks with quality medical providers yielding a geographically competitive, accessible, stable network that achieves company objectives
- Evaluating medical practices for member care, and trend quality compliance at the provider level
- Developing action plans and programs to support provider practices in continuous quality improvement using approved guidelines
- Responsible for provider education, contract compliance, and resolving provider concerns and issues
- Negotiating all Provider Network, casualty, and Hospital contracts on an individual basis and or in groups.
- Partnering with internal stakeholders to create a seamless experience for providers
- Ensure all enquiries are resolved satisfactorily and customer requirements within business rules are met
- Continuously managing risk of all providers and acting in areas where costs are exuberant
- Identifying and resolving network access gaps or perceived gaps
- Supplying monthly management reports
- Matric
- Diploma
- Regulatory Exams - RE05 - Preferred
- Bi-Lingual
- Sound understanding of the South African Health industry, plan options, and benefits, etc.
- Business Reporting skills
- Ability to develop interpersonal business relationships with network providers and internal business partners leading to high provider and member satisfaction
- Meeting targets and regulatory requirements.
- Good experience in collaborating with all medical provider types and, understanding how medical providers administration systems work, for claims to be submitted
- Working knowledge of behavioural health provider operations and analytical skills to resolve provider issues
- Excellent oral and written communication skills
- Computer literate - MS Office suite, i.e., Word and Excel necessary
- Intermediate understanding of claims risk profiling
- This position requires extensive travelling and the ability to travel to different provinces to visit providers.
