Job Description
To accomplish effective contract management and network design of the providers through the implementation of the agreed providers strategy and framework while complying with CCHI & SAMA rules& regulations to deliver effective price & cost management and projects savings .In addition ,aligning with sales & marketing to continuously developing new products & services that support business development &proposition in the insurance market and achieve business profitability and expansion goals .
Contract Mangement:
- Set up the contracts rules and standards with all providers for the best interest of the busines
- Supervise contracting (and engage whenever necessary)new providers ,new service codes and the renewal of contracts.
- Ensuring contracts compliance with the regulatory, renewals and licensing requirements.
Benchmarking:
- Introduce systems for comprehensive benchmarks for frequently billed items (regional and per network )
- Develop process, reference and guidelines for items that are not benchmarked to ensure that any item can be reasonably and fairly priced whenever requested by members or other business units.
- Develop pricing models, guidelines & benchmarks for optical and other unique services
Pricing ,Discounts and Coding:
- Revamp the coding system, including the introduction of unified parent codes, and ensure cleaning up redundancy and duplication
- Implement business obligations of ICD 10-am systems
- Ensure the resolution of defaults of the invalid & duplicate service codes and overbilling.
- Develop standard discount structure , PPD rules and slabs of volume discount
Cost Effectiveness:
- Develop (and negotiate whenever necessary) price reduction plans to achieve business goals
- Develop and enhance plans to agree with the providers on services bundling (in & out patients) and expansion of surgical packages
- Ensure (and Negotiate whenever necessary)that the prices of new & renewed contracts and addition of new services are consistent with the benchmarks and achieving the business targets
- Provide business stakeholders with price forecasting on regular basis and whenever necessary.
Network Design and Management:
- Ensure that the network of providers is comperhensive and covering all benefits for each class.
- Enhance , regularly ,the providers network (down/up grading) based on risk cost and business requirements
- Optimize accessible and affordable network .
- Optimize optical and dental providers network
- Manage pharmacy benefits including networking ,formularlies and refills systems
Volume Allocation:
- Enhance stepladder referrals system with regular updates to achieve best practice and cost effectiveness.
- Develop network of anchor providers and centers of excellence
- Manage volume re-allocation of all or specific services from one provider to another whenever indicated
Service Innovation:
- Explore and Develop new payment approaches to cope with business growth like paradigm shift ,prepaid services and accountable care organization
- Explore and develop partnership relations with strategic providers
- Develop providers ,physicians and service finder for website support and development.
- Introduce healthcare plans that respond to market needs ,health & benefits and business developments.
- Develop new products and services ,e.g. Fast track ,external doctors ,special arrangement (SPA) ,High skills physicians network ,maternity and uncovered services.
Coordination and Communications:
- Ensure that addition/deletion of contracts/providers ,amendments and significant contract milestone are communicated to the operation team and technical stalkeholders.
- Communicate regular price forecast to the commercial finance
- Communicate newtwork redesign ,referral system updates to operation team and sales
- Coordinate with sales ,marketing and commercial finance volume re allocation ,healthcare plans and network updates.
People Management:
- Provide leadership ,professional guidance and directions to the assigned team members.
- Preparing and overseeing KPI for the team.
- Ensure and facilitate goal setting ;manage and constantly review individual performance
- Provide regular feedback ,coaching ,and development
- Motivate ,empower and enable direct reports by providing technical expertise , necessry tools and support required to achieve the organizational development objectives
- Build the capabilities of the team members.
Skills
- 5 – 7 years
- Bachelor in medicine and surgery
- Medical practice
- Hospital management (preferrable)
- Contracting and pricing of services
- Good knowledge on CCHI rules & regulations
