Networks Manager – Dubai & Northern Emirates
NAS Administration Services LLC
مجموع سنوات الخبرة :29 years, 9 أشهر
o Review, compare and negotiate prices offered by new providers and current.
o Ensure the providers’ database (prices, healthcare practitioners, licenses, discount...etc.) is maintained in the system.
o Train new and existing providers on NAS procedures and systems.
o Coordinate; respond to all payers’ queries and requests related to networks; providing the payers when required with any report related to networks.
o Conduct random onsite audit to look for any false claims and / or fraud.
o Obtaining sign-off from providers semi-annually on all settled claims.
o Dealing with insured’s complaints related to medical network.
o Meeting network providers on regular basis.
o Monitor market situation to ensure that prices and discounts are of an acceptable rate.
o On-boarding of new providers to SCH scheme; that includes education function to train the providers on SCH medical policy; coding; systems and claims submission.
o Update the network providers of new protocols, policies and procedures.
o Ensures the accuracy of provider data entered into the provider database. And all related documentation is complete and accurate.
o Help in fixing system issues reported by providers during claims submission.
o Supports the functions of other departments like Claims and Call Center.
o Coaching, mentoring subordinates in the Provider Relations Section for the optimization of their personal potential in order to ensure that the department objectives are met and exceeded.
o Plan and conduct the post payment claims audit; on ground audit and data analysis to summarize the audit findings.
o Managing claims department procedures, guidelines and process flows.
o Handle ACE Life medical network such as contracting, negotiations, procedure setup and implementation as well as claims reconciliation and network expansion.
o Report all claims activities to direct management on a weekly and monthly basis such as Claims Production, Audit results, TAT, reinsurance cases and claims utilization reports.
o Update provider’s profiles, ACE medical network list, procedures coding and maintaining tariff.
o Visit the providers to set up network procedures.
o Handle internal and external audit.
o Operational and departmental management, staff training and evaluation.
o Case management: review and process all approval notifications from the TPA, ACE network and insured members.
o Customer service: coordinate and communicate with all customers including TPA, providers, brokers as well as direct insured members on claims and network related issues. To create a strong relation with all clients internal and external.
o Participated in the creation and launching medical claims department and system.
o Implementation of claims department procedures, guidelines and process flows.
o System Super User: training and supporting all System users to increase their efficiency and productivity. Documenting and designing the data flow charts for the new system customization.
o Audit and approve claims processed by the TPA.
o Analyze, review, examine and process all types of medical claims. Uploading EDI claims, DHA system uploads.
o Receiving tenders and quotations requests for life and medical; work on census provided, enter data to pricing module. Get the go ahead from home office and issue the quotations.
o Serving the policy holders Additions, Deletions and Salary Changes.
o Take care of billing issues, explain, solve problems if any and follow up of delinquent premium.
o Looking for prospects in the market place, making first contact, create a log of products purchased and renewal dates.
o Handling reimbursement claims and cash claims to claims department and create a log for it.
o Working on medical network extension in Oman.
o Customer Service Management (Internal and External).
o Building good relations with clients, brokers and home office.
o Claims assessment and adjudication.
o Handling reimbursement claims
o Customer Service for GCC branches.
o Medical management and case management.
o System Super User (system admin)
o Operational and departmental management; staff training.
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