Head - Network Provider Management & Wellness - Insurance

Primary Role Description - 

This position will be responsible for the development and execution of strategies that support the value proposition and goal of sustainable affordability by minimizing claims risk including the day to day management of the claims team.

The role will require the person to act as the technical expert in all areas of :

- Provider management: The job will develop high-level strategy to influence the healthcare delivery model thereby ensuring the provision of the best quality health care outcomes in the most affordable way.

- Enhancing provider network presence for effective customer service, provider negotiation and contracting (discounts, package pricing, additional services, differential treatment of Apollo Munich customers, different provider payment models like capitation etc), Provider relationship management, Provider audits. Apollo Munich to be established as the most preferred health insurer for providers at the same time manage claim cost most effectively.

- Leverage on analytics for gradation of providers, outlier analysis, quality and performance analysis, guided negotiations and trend monitoring.

- The job holder will also influence and provide health care leadership through the business whilst working with the medical profession, key industry bodies and government.

- Leverage on the strength of promoters: Stay at the forefront of knowledge in areas of developments in healthcare by liaising with Apollo Hospital group and leverage on the vast experience of Munich Re in claims management practices across the globe.

- Working across the sales, customer service and marketing teams to deliver improvements of the health of our customers in the most affordable manner in keeping with the values of the business.

- Key words: Customer experience, Steerage, Case management, discharge management, second opinion, home care, superior clinical outcome, clinical protocols, industry leadership and relationship management, Innovation, provider payment models, industry leadership, digitalization.

Key Roles & Responsibilities:

- Manage and develop team(s) to deliver improved healthcare services to our customers, case managing the interface with providers of care and customers for the best possible long term outcome.

- Establish and manage simple and streamlined pre-authorisation & re-imbursement processes and criteria that enhances the customer experience and improves provider relations.

- Proactively improve work practices and processes in order to maximise the team and departments performance.

- Deal with escalated customer queries, stemming from underwriting, pre-authorisation and case management issues.

- Set performance metrics and agree service level standards between claims and sales & service teams.

- Thorough analysis of historic data and forecasting, plan future resource requirements.

- Develop and execute strategies that support the goal of sustainable affordability by minimizing claims risk, including:

1. Developing and implementing effective risk and case management strategies

2. Negotiation with hospital and provider contracts for quality cost efficient services

3. Driving and influencing necessary industry and health service delivery reform

- Develop and provide leadership in relation to wellness models and programs. This could include:

1. Contribution to disease management and preventative health initiatives that improve quality of life, specific health outcomes and add value to health insurance of claiming and non claiming members

2. Promotion of evidence based clinical practice to providers and members so as to positively influence utilization, quality and safety of treatments and including the promotion of non-admitted health services where they can deliver more efficient and effective outcomes for specific health conditions.

Use analytics to drive strategy and informed decisions in areas of

1. Provider contracting to achieve the right geographical spread, right grade mix

2. Negotiate tariff

3. Monitor performance (medical, financial, customer)

4. Develop provider payment strategies and models

5. Define payment processing cycles to achieve best financial outcome for company without compromising customer experience

Basic Experience & Skills:

- Demonstrated experience in the health industry

- Extensive medical, insurance industry experience.

- Good organizational, planning and delivery skills.

- Ability to make considered business decisions based on explicit and implicit data and information.

- Diplomatic, self-confident and authoritative.

- Used to working in a high-pressure environment and meeting challenging service standards.

- Project management experience including of claims management IT systems or experience in working with evolved claims management systems

- Good presentation, communication skills

Judgement Skills - 

- Problem solving ability with the ability to consider out of the ordinary situations and know when it makes good business sense to override standard guidelines.

- Consideration must be given to clinical, often complex medical and policy issues in order to make decisions.

- Ability to proactively identify potential impacts of interventions, strategies

- Identification, facilitation of and consultation with stakeholders as appropriate.

- Ability to provide honest, accurate and timely feedback regarding performance, giving guidance and encouragement to develop potential.