Network Manager

Discovery Limited; Johannesburg; On-site; ZAR 600,000 - 900,000; Full time

Job summary

A leading healthcare organization seeks a Network Manager to optimize their provider network and ensure high-quality, cost-effective healthcare services for insured members. This role involves contract negotiations, case management oversight, and collaboration with internal teams to enhance healthcare delivery.

Qualifications

• 5-7 years experience in provider network management within a health insurer or managed care organization.
• Strong understanding of medical pricing models and healthcare regulations.
• Experience in negotiating provider contracts.

Responsibilities

• Develop and manage a robust network of medical service providers.
• Negotiate provider contracts and manage provider performance.
• Coordinate medical care for insured members and review treatment plans.

Skills

Negotiation

Relationship Management

Analytical Skills

Problem Solving

Communication

Tools

Healthcare Management Systems

Data Analysis Tools

Job description

Job Title: Network Manager

Job Summary

The Provider Network Manager will be responsible for developing, managing, and optimising the provider network to ensure high-quality, cost-effective healthcare services for insured members. This role involves establishing and maintaining relationships with healthcare providers, negotiating contracts, and ensuring compliance with regulatory requirements. Additionally, the incumbent will oversee case management activities, ensuring appropriate utilisation of medical services, coordinating patient care, and implementing cost-containment strategies.

Key Responsibilities:

Provider Network Management:

• Develop and maintain a robust network of medical service providers, including hospitals, clinics, specialists, and allied healthcare professionals.
• Negotiate and manage provider contracts, ensuring cost-effective reimbursement models while maintaining high service quality.
• Monitor provider performance, including adherence to agreed clinical protocols, service quality, and patient satisfaction.
• Implement network expansion strategies in line with business growth objectives and geographic coverage needs.
• Ensure compliance with healthcare regulations, accreditation standards, and contractual agreements with providers.
• Resolve provider disputes, claims issues, and grievances in a timely and professional manner.
• Collaborate with internal teams (claims, finance, compliance, and customer service) to optimize provider network performance.

Case Management & Utilization Review:

• Assess, plan, and coordinate medical care for insured members to ensure appropriate and cost-effective treatment.
• Review and approve treatment plans, pre-authorizations, and referrals in line with clinical guidelines and policy benefits.
• Work closely with providers, members, and insurers to facilitate seamless patient care pathways.
• Identify high-cost and high-risk cases for proactive intervention, ensuring optimal medical and financial outcomes.
• Educate members and providers on medical management policies, wellness programs, and preventive care initiatives.
• Monitor medical claims and utilization trends to identify opportunities for cost-containment and process improvement.

Qualifications & Experience:

• Minimum of 5-7 years of experience in provider network management, case management, or medical claims administration within a health insurer, healthcare administrator, or managed care organisation in Mozambique
• Strong understanding of medical service pricing models, reimbursement methodologies, and healthcare regulations.
• Experience in negotiating provider contracts and managing relationships with medical service providers.
• Familiarity with healthcare claims processing, pre-authorisations, and utilization management.

Key Skills & Competencies:

• Excellent negotiation and relationship management skills.
• Strong analytical and problem-solving abilities, particularly in healthcare cost containment.
• Knowledge of medical protocols, treatment guidelines, and insurance benefits.
• Ability to interpret medical reports, claims data, and provider performance metrics.
• Strong communication and stakeholder engagement skills.
• Proficiency in healthcare management systems and data analysis tools.
• Ability to work collaboratively across multiple teams and functions.

EMPLOYMENT EQUITY

The Company’s approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.