Provider Network Consultant

4 days ago

Durban, South Africa Watershed Consulting Full time

Our client in the healthcare insurance space is looking for a Provider Network Consultant in the KZN area.

Responsibility:

- Develop integrated networks with quality providers yielding a geographically competitive, broadly accessible, stable network that achieves company objectives.
- Evaluate practices in analysing member care, and trend quality compliance at the 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 in 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 take action in areas where costs are exuberant.
- Identify and resolve network access gaps or perceived gaps.
- Supply monthly management reports.

Qualifications:

- Matric
- FAIS Compliant
- RE 5 and Class of Business
- Valid Drivers Licence

Skills and Experience:

- At least 2-5 years of experience in a similar role
- Sound understanding of the South African Health industry, options, 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.

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