Assistant Manager - Managed Care

This role involves managing provider relationships to support the profitable growth of the business while ensuring alignment with departmental goals. The candidate will be responsible for negotiating prices, monitoring provider performance through key performance indicators (KPIs), and preparing detailed monthly reports to analyze network operations and utilization trends. These reports will aid management decision-making at both local and regional levels. The position requires timely resolution of provider-related issues, including billing and claims settlements, as well as conducting random audits of claims to maintain quality assurance.

Key Responsibilities

- Assist in managing provider relations by negotiating prices and ensuring provider KPIs contribute to business growth and departmental objectives.
- Develop monthly statistical reports to benchmark and review network operations and utilization trends for management.
- Intervene promptly to resolve provider-related issues such as billing or claims settlement discrepancies.
- Perform random audits on selected claims to ensure quality and accuracy in processing.
- Obtain signoff letters from providers after reconciling accounts to confirm mutual agreement on financial records.
- Update and maintain data related to provider addresses, discounts, tariffs, service charges, new codes, and specialties as needed.
- Manage case approvals, pre-authorizations, rejections, and processing within the company database, ensuring all information meets payment eligibility criteria.
- Conduct telephonic investigations and verifications related to claims and pre-authorizations.
- Take statements and consult with claimants, doctors, and other relevant parties to examine records and report potential fraud cases to management.
- Provide clear explanations of policy wordings to insured individuals and other stakeholders.
- Maintain clients’ pre-employment and periodic medical records, notify relevant parties about fitness or reassessment requirements, and prepare reports for bill settlements within and beyond policy scope.

Required Qualifications

- Must be a licensed medical doctor.
- A minimum of 3 to 4 years of relevant experience in provider relations, claims management, or a related healthcare field.

This position demands strong negotiation skills, attention to detail, and the ability to handle sensitive information with discretion. The ideal candidate will be proactive in resolving issues and capable of working collaboratively with multiple stakeholders to ensure smooth operations and compliance with company policies.