Senior Network Manager

Job Purpose

QLM is hiring for its Medical Department, this role will consist of building, scaling, and continuously improving the medical network, supporting various key departments in KPI development and tracking for medical providers. Responsibilities of this position include the development of the QLM’s provider network strategy, provider contracting, provider relations and operations to support provider service, network development, provider education, and product and market expansions.

The candidate will be reporting to the Chief Medical Officer, the ideal candidate will have a strong understanding of medical insurance, Insurance policies, claims management cycle, healthcare providers & vendor contracting. He or she will be responsible for overseeing medical provider relations, negotiating contracts, and ensuring network growth and efficiency.

Key Responsibilities:

• Establish excellent relationships with providers, assess their integration & empanelment to QLM's network by comparing their prices to contracted providers within the network, taking into consideration the providers’ location and the geographic distribution of the members.

• Liaise with network providers to resolve issues and complaints stemming from customer service, and maintain a performance log against healthcare providers.

• Conduct reconciliation meetings with the providers, this will include scheduling meetings and coordination with the medical claims team to ensure all reconciliations are undertaken with accurate information and concluded on time.

• Assess and evaluate, on an ongoing basis, the quality of services delivered by the providers to ensure that the members are receiving the best healthcare.

• Manage the delivery of training sessions and development programs to providers’ staff on QLM's systems, policies, and procedures.

• Ensure that the agreed terms are properly implemented, monitored and documented.

• Ensure Proper Mapping of ICD (CM-AM), CPT, CDA, among all International and Local codes.

• Manage network behavior through analytical methods - doctor profiling analysis, service-level behaviour, and trends within each provider.

• Conduct regular impact analysis to ensure accurate price valuations and underwriting in negotiations.

• Ensure all signed agreements adhere to local, regulatory & corporate outsourcing guidelines and requirements.

• Maintain relationships with key healthcare providers, TPAs, and international TPAs

• Ensure Letter of Guarantee (LOG) processes are adhered to by the providers.

• Develop and expand Medical Network to meet ever-growing customers' needs and demands.

• Negotiate with potential Medical Specialists for cashless facility and preferential outpatient, inpatient and surgical fees.

• Conduct annual due diligence assessments on appointed TPAs according to local regulatory guidelines and requirements.

• Monitor and ensure business efficiency and appointed TPAs' Service Level Agreements (SLAs) are met.

• Provide complaints resolution in relation to service delivery failure, claims, and payment issues with Medical Providers, TPAs etc.

• Analyze hospitals and panel Specialists' utilization data to develop appropriate strategic measures to manage and contain escalating medical costs.

• Maintain an accurate Score Card and accurately Re-Categorize the medical network on a monthly basis.

• Continuously maintain KYC standards and standardize providers contracts.

• Analyze all providers codes pricing and ensure accuracy via re-negotiations to ensure QLM's rates are the most favourable in the market.

• Maintain provider's average cost, accuracy of prescriptions/services and coding by continuous monitoring and deploying appropriate counter measures.

• Any additional task as assigned by the pillar head for any additional projects.

Qualifications and Experience:

• 5 – 7 years’ experience working in an Insurance company, within the capacity of a Network senior.

• Bachelor degree in finance, business administration or any related field

• Highly proficient in drafting, reading and writing Arabic & English

• High technical skill in Microsoft Suite programs (Word, Excel, Powerpoint)

• Experience of working in a regulated entity highly preferred.

• Proven ability to manage work flows effectively in a multi-stakeholder environment.

• Professional qualifications are preferred

About QLM:

QLM is the leading Life & Medical insurance company in the State of Qatar, aiming to provide ultimate healthcare insurance solutions, in line with the Qatar 2030 Vision. Encompassing excellence in medical standards and innovative technologies, tailor-crafted to meet member's needs both locally and internationally. Our goal is to be recognized by our partners, providers, clients and stakeholders as the preferred, trusted, long term insurer, delivering a world-class service.