Sr. Officer – Provider Control

Role Purpose

To establish a full control on providers' financial reconciliation and payments; playing a gate keeper role to ensure accuracy and avoid over payments to be made within agreed KPIs with stakeholders.

#

Key Accountabilities

Key Activities / Decision Areas

1

Medical providers control

·          Prepare the provider’s financial reconciliation and perform a role of gatekeeper of payments and ensure to apply the accurate payments.

·          Reconcile the Providers accounts from different systems including Accpac, Caesar and our internal documents to make sure all figures are accurately recorded and track historical record of the providers’ monthly payments.

·          Monitor & ensure accuracy of provider payments documentation flow requests sent by claims; and ensure all required supporting documents is in place prior to payments.

·          Identify the high value claims and inform the Anti-Fraud Unit to investigate in order to avoid any abuse in the providers’ payments.

·          Manage the financial part of the STA project and deductions to ensure an appropriate management, and assist the IT project team and Provider Relation Dept. in the new terminals installation.

·          Manage the recovery of over payments from providers to keep the payments log accurately.

2

Provider’s settlement

·         Generate the Commercial Financial Figures for Provider relations team as a baseline for decision making.

·         Ensure that prompt payment discounts and volume discounts are applied correctly.

·         Manage all of the negative Full & Final settlement and supervise the process of collecting the negative provider settlements amounts in order to secure accurate settlements for our accounts.

·         Resolve and reconcile provider’s yearly opening balances by Mid-year and coordinate with the Provider relations and claims department in order to settle the provider’s accounts in an efficient way.

3

Commercial analysis

·         Prepare the monthly STA collection report and analysis to present the collected/outstanding amounts and track the new providers who signed up for the new terminals.

·         Generate the Providers Issues Report to track the provider’s problems & report it to the management, to perform an active role in resolve such issues and uphold all necessary back-up documentation related to their issues.

·         Prepare the Unsettled Providers report to the Provider Relations team.

·         Monitor the variance between projected and actual costs through the Batches Received versus Projections weekly report.

4

External auditor’s requirements

·         Prepare the Top 20 Providers monthly report and analyse it in terms of Net billed.

·         Assist in the Year-end Top 20 providers report and coordinate with the Finance Operations & Provider Relations team in order to present the top 20 provider payment as well as the settlement letters.

5

Providers fraud controls

·          Build the Fraud providers report to monitor all of the abuse providers and analyse the (on-hold/ processed/ cancelled) payments, also to present the outstanding & recovered amounts.

·          Manage all the fraud provider payments (on hold/ release/ terminated) provider’s payments and hold fraud payments if it’s already in the pipe line.

·          Control the fraud recovery deductions and guarantee to fully deduct the amounts and report it to the Provider Relations Department, Finance Operations and Anti-Fraud Unit by providing them with the correct figures.

·          Maintain and uphold all the necessary documents related to the providers fraud list.