Requirements - MBBS or Bachelor's Degree in Healthcare Administration, Business Management, with a preferred background of master’s level studies in data analysis or business administration
- 8+ years of experience in claims management and tariff negotiation within the healthcare industry
- Proven track record of implementing process improvements to enhance claims efficiency and reduce costs.
- Strong background in data analysis and demonstrated ability to work with data to solve complex problems, utilizing advanced analytical tools and methodologies
- Strong understanding of rules-based automated claims processing systems and prior authorization workflows.
- Experience in tariff negotiation, provider network management, and benefits design across diverse markets.
- Excellent leadership and communication skills, with the ability to collaborate effectively across cross-functional teams.
- Analytical mindset with proficiency in data-driven decision-making and performance metrics evaluation.
- We are seeking a dynamic, data-driven, and experienced Director of Claims and Tariff Management to lead our efforts in optimizing claims processing and tariff management across our international markets, with a primary focus on Egypt and Nigeria.
- Join Reliance Health and be part of a team dedicated to transforming healthcare services in emerging markets.
- Apply now and contribute to our mission of making quality healthcare accessible and affordable for emerging markets.
Key Duties
Cost Reduction and Fast Reimbursement Cycles:
- Implement strategies to reduce costs and ensure rapid reimbursement cycles for claims across all active markets, enhancing overall operational efficiency and customer satisfaction.
Efficiency Improvement and Unpaid Claims Reduction:
- Oversee initiatives to enhance the efficiency of claims and optimize team productivity and processing systems to reduce unpaid claims backlogs and streamlining workflows for faster adjudication.
Automation and Rules-Based Claims Processing:
- Lead the improvement of rules-based automated claims processing engines, leveraging technology to enhance accuracy, speed, and consistency in claims adjudication.
Prior Authorization Enhancement:
- Enhance the accuracy and turnaround time for complex prior authorization requests, ensuring timely access to necessary healthcare services for our members.
Tariff Management and MER Improvement:
- Drive improvement in turnaround time for tariff renegotiations and enhance Medical Expense Ratios (MER) through data-driven tariff and provider network tiering strategies.
Benefits Design and Operationalization:
- Support the design and operationalization of benefits across our B2B and B2C offerings in multiple international markets, ensuring alignment with regulatory requirements and customer needs.
Fraud, Waste, and Abuse Mitigation:
- Collaborate with provider and case management teams to identify and mitigate claims loss attributed to fraud, waste, and abuse, implementing proactive measures to safeguard against financial losses.
