Payers Management Excellence Manager

2 weeks ago


Jeddah, Saudi Arabia Nahdi Full time

Develop and manage the excellence deployment for all payer operation and claim requirements in line with regulator policies and ensure proper collaboration with Nahdi departments to ensure the best outcomes via established SLA & SOPs.

**Accountabilities**

**Contracting & Benefit File Excellence**:

- Ongoing maintenance of all payers contract to comply with regulators guideline, market practice & pharmacy operation
- Mange and update benefits file for all contracts according to regulator policies, payer requirements and policy table of benefits (TOB) in collaboration with medical training team to ensure right medical judgment
- Manage & update payer benefits file update in IMF and POS.
- Conduct regular benefits file review and analysis to improve the compliance
- KPIs: contract compliance, rejection ratio driven by benefit file, on-time benefit file management across all stakeholders internal / external

**Payer Operation Excellence**:

- Develop and ensure the deployment of all operation guideline as per the regulator policies and payer contract terms
- Ongoing guideline review and update according to any changes
- Conduct regular compliance review meetings with cross function to share compliance analysis and reports in order to develop the correction action plan in collaboration with IT, OPEX and claim teams
- KPIs: rejection ratio driven by operation malpractices

**Payer Claim Excellence**:

- Measure and ensure the deployment of all claim requirement as per the regulator policies and payer contract terms
- Ongoing claim requirements review and update according to any changes
- Conduct regular claim submission review meetings with cross function to share compliance analysis and reports in order to develop the correction action plan in collaboration with IT, OPEX and claim team
- KPIs: claim efficiency %, on-time claim submission, resubmission, and settlement.

**Team Management**:

- Manage the performance of the assigned team through monitoring the KPIs achievement, coaching, following up any obstacles, provide performance feedback and conversations, coaching etc. to ensure the achievement of the set objectives.
- Develop system and processes with internal and external stakeholders based on each contract and payer specifications and requirements (financial, legal and operational) to ensure optimum business performance.

**Work Environment**
- Indoors : 80%
- Outdoors : 20%
- Working Days : 5 Working Days
- Days off : 2 Days Off
- Working Hours : 8:00 AM - 5:00 PM (1 hour break)

**Job Requirement**

**Education
- Medical Bachelor

**Experience
- 3-5 Years of Experience in Management - Providing medical services to insurance companies, corporate or government

**Computer Skills
- MS Office Suite
- Awareness of Insurance Systems

**Languages
- English
- Arabic



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