Senior Executive Manager - PR Contract Management

To accomplish effective contract management and network design of the providers through the implementation of the agreed providers’ strategy and framework while complying with CCHI & SAMA rules& regulations to deliver effective  price & cost management and projects’ savings .In addition ,aligning with sales & marketing to continuously developing new products & services that support business development &proposition in the insurance market and achieve business profitability and expansion goals .

Contract Mangement:

·       Set up the  contracts’ rules and standards with all providers for the best interest of the busines

·       Supervise contracting (and engage whenever necessary)new providers  ,new service codes and the renewal of contracts.

·       Ensuring contracts’ compliance with the regulatory, renewals and licensing requirements.

Benchmarking:

·       Introduce systems for comprehensive benchmarks for frequently billed items (regional and per network )

·       Develop process, reference and guidelines for items that are not benchmarked to ensure that any item can be reasonably and fairly priced whenever requested by members or other business units.

·       Develop pricing models, guidelines & benchmarks for optical and other unique services

Pricing ,Discounts and Coding:

·       Revamp the coding system, including the introduction of unified parent codes, and ensure cleaning up redundancy and duplication

·       Implement business obligations of ICD 10-am systems 

·       Ensure the resolution of defaults of the invalid & duplicate service codes and overbilling.

·       Develop standard discount structure , PPD rules and slabs of volume discount

Cost Effectiveness:

·       Develop (and negotiate whenever necessary) price reduction plans to achieve business goals

·       Develop and enhance plans to agree with the providers on services’ bundling (in & out patients) and expansion of surgical packages

·       Ensure (and Negotiate whenever necessary)that the prices of new & renewed contracts and addition of new services are consistent with the benchmarks and achieving the business targets

·       Provide business stakeholders with price forecasting on regular basis and whenever necessary.

Network Design and Management:

·       Ensure that the network of providers is comperhensive and covering all benefits for each class.

·       Enhance , regularly ,the providers network (down/up grading) based on risk cost and business requirements

·       Optimize accessible and affordable network .

·       Optimize  optical and dental providers’ network

·       Manage pharmacy benefits including networking ,formularlies and refills systems

Volume Allocation:

·       Enhance  stepladder referrals system with regular updates to achieve best practice and cost effectiveness.

·       Develop network of anchor providers and centers of excellence

·       Manage volume re-allocation of all or specific services from one provider to another whenever indicated

Service Innovation:

·       Explore and Develop new payment approaches to cope with business growth like paradigm shift ,prepaid services and accountable care organization

·       Explore and develop partnership relations with strategic providers

·       Develop providers ,physicians and service finder for website support and development.

·       Introduce healthcare plans that respond to market needs ,health & benefits and business developments.

·       Develop new products and services ,e.g. Fast track ,external doctors ,special arrangement (SPA) ,High skills physicians network ,maternity and uncovered services.

Coordination and Communications:

·       Ensure that  addition/deletion of  contracts/providers ,amendments and significant contract milestone are communicated to the operation team and technical stalkeholders.

·       Communicate regular price forecast to the commercial finance

·       Communicate newtwork redesign ,referral system updates to operation team and sales

·       Coordinate with sales ,marketing and commercial finance volume re allocation ,healthcare plans  and network updates.

People Management:

·       Provide leadership ,professional guidance and directions to the assigned  team members.

·       Preparing and overseeing KPI for the team.

·       Ensure and facilitate goal setting ;manage and constantly review individual performance

·       Provide regular feedback ,coaching ,and development

·       Motivate ,empower and enable direct reports by providing technical expertise , necessry tools and support required to achieve the organizational development objectives

·       Build the capabilities of the team members.

·       5 – 7 years

·       Bachelor in medicine and surgery

·       Medical practice

·       Hospital management (preferrable)

·       Contracting and pricing of services

·       Good knowledge on CCHI rules & regulations