Director of Claims and Tariff Management at Reliance HMO

Description

• Reliance Health is 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 Responsibilities:

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.

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.