ROLE PURPOSE:

To be responsible for the commercial and medical management of the portfolio providers in order to resolve the identified trends,unit cost control and obtain competitive commercial terms and reconciliation outcome within the agreed target forecasting,timescales and quality standards.

KEY ACCOUNTABILITIES:

1. Reconciliation of the accounts

• Set the targets aligned with the overall forecast.

• Review the statements of accounts and ensure it's quality before sending to the providers.

• Analyse the statement with documentation including the achievable amounts.

• Negotiate the reconciliation with the providers to achieve the set targets.

• Document the reconciliation facts and send feedback to the claims department and regional manager.

• Prepare presentation to the owners of top 20 provider,at least once/year to highlight the trends and errors.

• Ensure that the reconciliation is conducted on regular basis and in line with the CCHI regulations.

2. Contract management

• Review the existing and renewed contracts to identify and resolve issues that ensure better commercial terms and improve operation.

• Agree with the providers on the prices of the new service codes to be aligned with the standard Bupa prices and/or the usual & customary prices.

• Maximize the commercial benefit by bundling of services and achieve preferable billing schedules.

3. Better commercial terms

• Set the targets aligned with the overall forecast.

• Prepare the proposals for better prices and discount structures of the frequent services and package in coordination with the commercial team.

• Negotiate and agree with the providers for better prices.

• Intimate the agreements to the commercial and support team for uploading and implementation.

• Negotiate better deals for the identified high value claims on real time basis before sending the claims.

• Monitor the compliance of the providers with the agreements on their claims presentation.

4. Communications and trends resolutions

• Identify the unfavorable trends in medical practice of the providers.

• Prepare presentations and conduct education sessions with the medical staff of the identified providers twice a year.

• Communicate identified issues that improve the providers management to the claims,relation team and commercial teams.

• Keep continuous relation with other medical team in the business including the hospitals audit doctors.

• Attend to members and providers complaints on medical issues.