About KaeloKaelo 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 DescriptionThe Networks Manager is responsible for the management of the multi-disciplinary network ensuring that contractual obligations (management of Contracts 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. The role reports into the Divisional Head Network and Risk executive.Network ManagementDrive the strategic objectives of the company by ensuring network growth and stability, an informed provider who is a partner in the delivery of appropriate and cost-effective healthcare.Own and manage the primary care benefit stack, ensuring that the benefits marketed and sold can be delivered efficiently via the administration system and network of providers.Develop and implement sound administrative, communication and operating 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 standard operating procedures (SOP's) are followed.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 ManagementThe Head of Networks 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 ManagementThe Head of Networks will ensure that the 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-contractedCo-ordination and management of provider profiling, peer review and intervention with outliers.Risk Analysis as a member of the risk forum.DemographicsGeographic'sIndividuals to groupsIdentification of high-risk high claiming membersDisease BurdenEmployer profileClient executive of Prime Cure clients including SchemesNegotiation of contracts and fees.Design of products and benefits.Analysis of risk factors and potential solutions.Ensure that each service level agreement (SLA) 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 and Information ManagementCompile daily, monthly, quarterly, and ad hoc reports for internal and external submissions to allocated providers.Collect data timeously for the compilation and completion of reports to Divisional Head Network and Risk executive.Complete monthly quality audits on all network related SOP's- utilisation, claims to capitation fee ratio and effect of managed care interventions.Ensure data and information is maintained and accurate for the business unit and its functions.Ensure that volumes and strategic objective targets are met for the assigned business functions.Maintain data and information relevant to service and operations for the purpose of conducting analyses that influence service specific decision making.Identify opportunities and the development of a financially viable long-term service and operational plans.Best Practise and Continuous ImprovementIdentify opportunities by evaluating current business trends, best practise research and principles.Work closely with all business units to enhance and promote positive feedback loops and improvements.People and Team ManagementEnsure participative leadership and strong communication within the team.Collaborate with all business areas.Coach and manage peer to peer learning.Develop the team and ensure staff are well-trained on the relevant technologies that they support/manage.Manage the team's budgets, targets, performance objectives, standards and projects.Planning and AssessmentsDetermine service centre and claims operational strategies by conducting:AssessmentsPerformance ReviewCapacity PlanningProductivity QualityQualificationsWork Experience:At least 5 years' experience in the healthcare Industry/ Insurance at a senior level.3 years project management/paralegal experience.
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