Networks Manager

4 weeks ago

Johannesburg, South Africa Kaelo Full time

**Company Description** About Kaelo**
Kaelo provides essential healthcare solutions ensuring the physical and psychosocial wellbeing of all South Africans towards lasting social change. Kaelo meets the Healthcare needs of Corporate and Retail clients across South Africa - products offerings include Medical Insurance, Medical Aid, Gap Insurance, Kaelo Money and employee assistance programmes.

The Networks Manager is responsible for the management of the multi-disciplinary network ensuring that contractual obligations (management of Contracts 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. The role reports into the Divisional Head Network and Risk executive.

Network Management

Drive the strategic objectives of the company by ensuring network growth and stability, an informed provider who is a partner in the delivery of appropriate and cost-effective healthcare.

Own and manage the primary care benefit stack, ensuring that the benefits marketed and sold can be delivered efficiently via the administration system and network of providers.

Develop and implement sound administrative, communication and operating 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 standard operating procedures (SOP’s) are followed.

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 Head of Networks 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 Head of Networks will ensure that the 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 (SLA) 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 and Information Management

Compile daily, monthly, quarterly, and ad hoc reports for internal and external submissions to allocated providers.

Collect data timeously for the compilation and completion of reports to Divisional Head Network and Risk executive.

Complete monthly quality audits on all network related SOP’s
- utilisation, claims to capitation fee ratio and effect of managed care interventions.

Ensure data and information is maintained and accurate for the business unit and its functions.

Ensure that volumes and strategic objective targets are met for the assigned business functions.

Maintain data and information relevant to service and operations for the purpose of conducting analyses that influence service specific decision making.

Identify opportunities and the development of a financially viable long-term service and operational plans.

Best Practise and Continuous Improvement

Identify opportunities by evaluating current business trends, best practise research and principles.

Work closely with all business units to enhance and promote posit

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