Head - Provider Management - Health Insurance - IIM/ISB/MDI/FMS

Key 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-authorization & reimbursement 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-authorization 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:

a. Developing and implementing effective risk and case management strategies

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

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

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

a. 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

b. Promotion of evidence based clinical practice to providers and members so as to positively influence utilisation, 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 :

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

b. Negotiate tariff

c. Monitor performance (medical, financial, customer)

d. Develop provider payment strategies and models

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

Basic Experience & Skills :

- MBA from a reputed institute

- 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