Provider Networks Consultant

•             Develop integrated networks with quality providers yielding a geographically competitive, broadly accessible, stable network that achieves company objectives.

•             Evaluate practices in analysing member care, trend quality compliance at 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 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 act in areas where costs are exuberant.

•             Identify and resolve network access gaps or perceived gaps.

•             Supply monthly management reports.

•             Any other duties as assigned by the company from time to time

Requirements

•             Matric

•             Commercial diploma

•             FAIS compliant or significant progress towards compliance

•       At least 2-5 years experience in a similar role

•             Sound understanding of the South African Health industry, options, and 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.