Provider Tariff and Resolutions Manager

Job Objective:

Responsible for developing, maintaining, and optimizing tariff structures for all tiers and cadres of partner healthcare providers.

Negotiate and manage tariffs for hospitals, clinics, and other partner providers to ensure cost-effective, high-quality healthcare services for insured members. Resolve tariff related escalations and ensure cost effective healthcare services for insured members.

RESPONSIBILITIES:

• Develop and implement provider tariff models across all tiers and cadres of provider
• Maintain an up-to-date database of provider tariffs and contracts
• Lead all negotiations with hospitals, clinics, and other providers regarding service rates and update contract terms.
• Ensure tariffs are fair, competitive, and aligned with the organisation’s goals.
• Benchmark against competition’s tariff to ensure efficiency and cost control
• Work in collaboration with the claims team to analyse medical cost trends, claims data, and provider performance to inform tariff adjustments
• Identify areas for cost optimization and value-based pricing opportunities.
• Support provider on-boarding and contract implementation processes.
• Oversee the tariff negotiation team and ensure efficiency in tariff negotiations, appropriate provider tiering and prompt close out of tariff reviews
• Supervise the resolution team to ensure prompt closure of point of care negotiations
• Ensure prompt upload and approval of negotiated tariff on the core business application
• Provide coaching, training, and support to ensure consistent handling and resolution of escalations by the resolution team.
• Act as a liaison between customers, providers, contact centre, and other internal stakeholders to facilitate prompt resolution and approval of pre authorization requests
• Work across the various team to identify the root cause and lead process improvements
• Communicate outcomes clearly and professionally to customers and partners.
• Ensure prompt resolution of all providers and enrollees’ complaints.
• Tracks and monitors all incoming escalations and ensures they are resolved within 24 hours by the appropriate issue owner
• Ensure that healthcare providers comply with the agreement concerning billing and quality of medical care.
• Prepare regular reports on provider negotiations, tariff trends and unit operations
• Assists the unit head on all other operation matters
• Any other duties may be assigned by the unit head

Education/ Professional  Qualification:

• MBBS/MBChB
• Relevant postgraduate (MPH, MSc, MBA) and/or professional qualification would be an added advantage.

Experience:

3 to 5 years professional in related position.