Our client in the healthcare insurance space is looking for a Provider Network Consultant in the KZN area.
• Develop integrated networks with quality providers yielding a geographically competitive, broadly accessible, stable network that achieves company objectives.
• Evaluate practices in analysing member care, and trend quality compliance at the provider level.
• Develop 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
• Negotiate all Provider Network, casualty, and Hospital contracts on an individual basis and or in groups
(IPA’s and discipline-specific groups) where appropriate.
Partner with internal stakeholders to create a seamless experience for providers.
• Ensure all enquiries are resolved satisfactorily and customer requirements within business rules are met.
• Continuous risk management of all providers and take action in areas where costs are exuberant.
• Identify and resolve network access gaps or perceived gaps.
• Supply monthly management reports.
• FAIS Compliant
• RE 5 and Class of Business
• Valid Drivers Licence
Skills and Experience:
• At least 2-5 years of experience in a similar role
• Sound understanding of the South African Health industry, options, benefits, etc.
• 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.
• Must have experience in working with all provider types and understand the logic as to how providers’ administration systems work for claims to be submitted.
• Must have a working knowledge of behavioural health provider business operations and analytical abilities to resolve provider issues.
• Excellent oral and written communication skills
• Computer literate - MS Office suite, i.e. Word and Excel a must.
• A good understanding of claims risk profiling.
• This position requires extensive travelling.
• Ability to travel to all providers.