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.<br/><br/>#J-18808-Ljbffr