Provider Relationship Specialist at Kaelo

Job Description

• The Provider Relationship Specialist is responsible for the day to day management of the multi-disciplinary network.
• Ensuring that contractual obligations with medical schemes, insurance and primary care products are established and maintained.
• Maintaining strong relationships with DSP’s via periodic engagement and implementation of standards and to manage and maintain quality assurance checks. Query resolution and effective interaction management. Manage contracts and service level agreements, through effective reporting and administration.

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

Management of Multi-disciplinary Network:

• Establish and maintain a Provider Network to serve patients in accordance with contractual obligations with medical schemes, insurance and primary care products.
• Ensure all required documentation is obtained from the provider prior to activating the contract
• 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
• Traveling may be required to visit for elite and contravening practices
• 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 all stakeholder are kept informed of relevant progress work items or escalations
• 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
• Provide reporting on engagement with providers
• Use of data to effectively identify and engage non-performing sites

Qualifications

SPECIAL REQUIREMENTS

• Ability to maintain confidentiality, problem solve, negotiate and communicate
• Ability to work in fast paced , High pressure environment
• Valid SA Driving licence

PERSON DETAILS: WORK EXPERIENCE

REQUIRED

• At least 3 years’ experience in the Medical Scheme or Healthcare Administration industry in a client support or provider Management roll

PREFERRED

• Proven work experience as a client or provider Management role

EDUCATION: QUALIFICATIONS: ACCREDITATIONS WITH PROFESSIONAL BODY

REQUIRED

• Grade 12 or equivalent NQF 4 certificate

PREFERRED

TECHNICAL SKILLS OR KNOWLEDGE

REQUIRED

• Computer Literacy – Microsoft Excel, Word and PowerPoint
• Strong phone, email (written) and inter-person communication skills

PREFERRED

• Strong Knowledge of Medical Scheme Industry (Optom , Pharmacy , Dental , GP , Hospital)