Job Description
Role Purpose:
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.
Key Accountabilities:
1- Contract Management;
- Set up the contracts rules and standards with all providers for the best interest of the business
- 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.
- New Providers facility field visit, evaluation & scoring.
2- 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.
3- Pricing, Discounts and Coding;
- Revamp the coding system and ensure cleaning up redundancy and duplication.
- Ensure the resolution of defaults of the invalid & duplicate service codes and overbilling.
- Develop standard discount structure, PPD rules and slabs of volume discount
4- 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 & outpatients) 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.
5- Network Design and Management;
- Ensure that the network of providers is comprehensive 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.
- Practice type network management.
6- Volume Allocation;
- Enhance stepladder referrals system with regular updates to achieve best practice and cost effectiveness.
- Develop network of anchor providers and centres of excellence
- Manage volume re-allocation of all or specific services from one provider to another whenever indicated
7- 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
- 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.
8- Coordination and Communications;
- Ensure that addition/deletion of contracts/providers ,amendments and significant contract milestone are communicated to the operation team and technical stakeholders.
- Communicate regular price forecast to the commercial finance
- Communicate network redesign, referral system updates to operation team and sales.
- Coordinate with sales, marketing and commercial finance volume re allocation ,healthcare plans and network updates.
9- 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, necessary tools and support required to achieve the organizational development objectives
- Build the capabilities of the team members.
Skills
- Familiarity with healthcare pricing and emerging models of care in the market.
- Analytical mindset & Presentation skills.
- Hospital management (preferrable)
- Contracts & Prices negotiations.
- Good knowledge of health insurance market regulations.
- 2 years in medical practice would be an advantage.
- Health Economics/Healthcare & Business Administration related studies would be an advantage.
Education
Medicine and Surgery
