Role Purpose
- Receive inquiries and communication related to network providers through dedicated channel of communication
- Handle complaints from patients/providers and resolve assigned providers requests timely
- Ensure that issues, complaints, or other communications received are registered in the appropriate tool in order to maintain proper tracking of information
- Achieve timely resolution of minor issues and escalate issues internally to reach closure
- Ensure closure of issues or queries is completed within agreed TAT with providers
- Capture and register feedback in the system and involve the superiors when necessary
- Channel customer feedback and conduct follow-ups if and when required
- Maintain documentation on claims against assigned network providers and make recommendations to management regarding providers continued network participation
- Send all network providers communication such as circulars and outlier letters
- Maintain and log all provider terminations and related warning letters
- Send any regulatory changes on policy or healthcare decisions received from the regulators
- Contribute in generating providers interaction dashboards necessary to amend root cause analysis and resolution of TATs
- Analyse and recommend solutions related to handling recurrent concerns
- Initiate, arrange and conduct providers initial trainings and any ad hoc trainings
- Contribute actively to the process chain by providing outcomes on service performance, issues closure and communication logs related to network providers
- Ensure efficiency and quality standards are met on all processes by monitoring TATs
- Contribute towards cost containment strategies and other initiatives
- Monitor providers operational processes to recommend changes when and if needed
- Work on projects/initiatives of limited complexity in a support role
- Issue Standard Provider Contracts in accordance with prescribed TATs specified in contractual terms
- Verify all legal documentation of contracts and execute all necessary updates related to the Power of Attorney, expired DOH and DED licenses, etc.
- Issue addendums to contracts based on agreed rates by the contracting team
- Ensure that all legal documents are signed by the provider and the CMOO and are available in the provider folder (e.g. addenda, etc.)
- Maintain/allocate all provider profiling e-mails related to new providers empanelment/branch additions
Key Requirements and Qualifications
- Minimum 2 years of experience working in health insurance industry
- Experience in customer services or relationship/complaint management is a must
- Bachelor's degree in business or an equivalent of 5+ years of similar experience
- Medical/paramedical degree is preferred
Skills and Competencies
- Good command of written and spoken English and Arabic
- Basic analytical, execution, problem solving and decision-making skills
- Basic knowledge of health insurance concepts
- Knowledge in claims coding and payment structure is a plus
