Health Partner Networks Operations Manager at Kaelo Engage

Job Description

• The Partner Networks Operations Manager is responsible for the management of the multi-disciplinary network ensuring that contractual obligations (management of Contacts and Service Level Agreements) with medical schemes, insurance and primary care products are established and maintained. They are also responsible for maintaining strong relationships and the implementation, management and maintenance of standards and quality assurance.

KEY OUTCOMES (not limited to) Level 4 and 5 process elements

stable national network of providers ensuring that the member base has access to a contracted provider

Network Management –

• ·       Support the business by ensuring that members and policyholders have access to primary healthcare benefits via a multidisciplinary network of healthcare providers at an affordable and sustainable rate.
• ·       Drive the strategic objectives of the company by ensuring network growth and stability, a happy educated provider who is a partner in the delivery of rational appropriate and cost-effective healthcare.
• ·       The ownership and management of the primary care benefit stack, ensuring that the benefits marketed and sold can be delivered efficiently via the administration system and network of providers.
• ·       Train providers in keeping with Prime Cure services, policies and procedures.
• ·       Develop and implement sound administrative, communication and operational systems to ensure consistent service delivery
• ·       Set work standards and ensure that these standards are met
• ·       Implement quality assurance procedures within the provider network
• ·       Resolve queries between funders, Prime Cure and service providers.

Ensure all interactions with providers are documented and SOP’s are followed

They will have oversight of the following items which are implemented by the Networks team:

• ·       All providers contracted to Prime Cure must have signed a valid contract and completed the information sheet and provided Prime Cure with all required documentation, for example BHF registration, HPCSA certificate
• ·       Management of yearly Confirmation of Service Agreements upon communication of new rates
• ·       Annual Fee negotiations with various providers including the Hospital networks, pharmacy groups, laboratories and other disciplines.
• ·       Ensure Managed Care Accreditation

Member and Provider Risk Management

• ·       The Partner Networks Manager supports and manages the design, implementation and evaluation of member/policyholder management and provider utilisation programmes thereby ensuring that members receive, and providers provide rational appropriate cost-effective healthcare. The main objective of these programmes is to ensure that members lead a healthy, happy, and productive life

Product and Scheme Management

• ·       The Partner Networks Manager ensures that the numerous Kaelo Health option benefits including that of Schemes, white label products and other Insurer products have the related documentation and delivery is as per the rules and policy documents.
• Negotiations of fees with all providers – contracted and non-contracted
• Co-ordination and management of provider profiling, peer review and intervention with outliers

Risk Analysis as a member of the risk forum

• ·       Demographics
• ·       Geographic’s
• ·       Individuals to groups
• ·       Utilisation
• ·       Identification of high-risk high claiming members
• ·       Disease Burden
• ·       Employer profile

Client executive of Prime Cure clients including Schemes.

• ·       Negotiation of contracts and fees
• ·       Design of products and benefits
• ·       Analysis of risk factors and potential solutions

Service level agreement management

• ·       Ensure that each service level agreement is adhered to and met by the relevant business unit owner
• ·       Monitor trends within the business that may adversely affect the SLA and ensure the line manager and relevant business unit owners are kept informed
• ·       Ensure all queries are dealt within contracted SLA
• ·       Ensure all provider details are kept up to date on MIP and provider lists

Reporting

• ·       Compile daily, monthly, quarterly, and ad hoc reports with precision and quality and submit these internally and externally at the agreed deadline dates for providers allocated to you
• ·       Collect data timeously for the compilation and completion of reports to Divisional Head Network and Risk executive
• ·       Complete quality audits monthly on all network related SOP’s
• ·       Utilisation
• ·       Claims to capitation fee ratio
• ·       Effect of managed care interventions
• ·       Underwriting

Qualifications
SPECIAL REQUIREMENTS

Communication skills, Industry experience and knowledge

PERSON DETAILS: WORK EXPERIENCE

REQUIRED

• At least 5 years’ experience in the healthcare Industry/ Insurance at a senior level
• 3 years project management/paralegal experience

PREFERRED

EDUCATION: QUALIFICATIONS: ACCREDITATIONS WITH PROFESSIONAL BODY

REQUIRED

• Project Management
• Business management

PREFERRED

• Health Regulatory or Paralegal

TECHNICAL SKILLS OR KNOWLEDGE

REQUIRED

• Decision Making Skills
• Organisational Skills
• Communication Skills
• Negotiation Skills
• Strategic Planning Skills
• Ability to work well within a team
• Leadership Skills
• Ability to work under stress and tight deadlines
• Knowledge of the Healthcare Industry

PREFERRED

• Knowledge of the Healthcare Industry

Additional Information
PERSONAL ATTRIBUTES : COMPETENCIES 

• Accountability
• Communication
• Business writing skills
• Efficient and effective mindset
• Planning and organisation
• Resilient and adaptive
• Self-development
• Significance and values oriented
• Ethical