Partner Networks Manager

Company Description

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.

**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
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: