Director of Provider Network and Claims

Overall Purpose of the Role

At International SOS we work to protect global workforces from health and security threats. We make a meaningful impact every day by safeguarding people and saving lives worldwide, 24 / 7.

for our Facts & Figures!

The Head of Provider Network and Claims, TRICARE Overseas Program (TOP) is responsible for the overall global operational performance and execution of the TOP provider network administration, global claims, and TOP enrollment.

A subject matter expert and lead for Global Claims accountable for executing strategies to meet contractual KPIs and enabling beneficiary and provider satisfaction.

Engages global teams to provide optimum beneficiary experiences, driving consistency, cost-effective solutions while leveraging data-led decisions and infusing new methodologies and / or technology.

Drives end to end value for sustained scalable performance, develops talent management and retention strategies to ensure DHATOP PMO trust and satisfaction.

Member of TOP Operations Leadership Committee focused on driving results, risk mitigation and overall performance. A key contributor to the overall TOP strategy.

Key Responsibilities

• Lead, manage, and oversee the TOP Provider Network and Claims Service Delivery
• A major contributor to the overall TOP strategy and business priorities.
• Embeds a performance culture, framework and review processes to achieve service levels and improvements against set targets.
• Responsible for process improvements and driving results from DHA audits.
• Builds and maintains effective internal and external stakeholder relationships.
• Proactively assesses and interpret the dynamics of a complex and changing global business, and applies data driven insights to drive performance, client trust and confidence and to meet defined business priorities.
• Instills a process culture with establishing end-to-end structure across entire remit; mitigates business risks through the documentation and standardization of processes.
• Provider & Administration of Claims : Leads claims management and performance, claims innovation and customer service, oversees / management of WPS (sub-contractor), ensures quick resolution of critical claims issues, participates in Semi-annual audits
• Network Administration : Responsible for TOP network verification / credentialing of new and on-going network maintenance;
• evaluates network adequacy, devises strategy, and executes; education and training of providers for TRICARE claims and program adherence, promotes the use of electronic submission and payment methods and that claims issues are resolved promptly and accurately;

leads TRICARE’s pricing efforts with providers; participates in semi-annual audits.

• TOP Enrollments : Leads and manages TRICARE Prime and Select Enrollment (Select, Prime & Spreadsheets); provide excellent quality of service to clients, meeting and exceeding contractual and client expectations.
• Philippines Network Certification : Functionally manages the Philippines team to validate the provider network and claims against fraudulent activity and aligns with TOPS and SPIN network to ensure quality / accuracy.

Ensures the development of strong relationships with network providers.

Required Qualifications

Required Skills and Knowledge (Brief description of technical knowledge or skills needed to perform the job)

• Preferred background in Claims, Financial Services / Insurance, Customer Service, Provider Network Services
• Demonstrated confident decision making, influencing, prioritization, change management and conflict resolution
• Strong leadership and management skills within a matrix organization
• Effective both strategically and at an operational level
• Effectively balance client needs with commercial considerations
• Innovator who generates new ideas for improved services
• Cultural awareness across multiple national jurisdictions
• Interpersonal and rapport building; strong EQ awareness and skillset
• Professional presentation and communication

Required Work Experience (Brief description of the job-related experience needed to perform the job)

10 -15 years of team and performance management experience at a senior level

Required Qualifications (Brief description of the educational background needed to perform the job)

Bachelors of Science; and preferably a post graduate degree in management, finance, or accounting

Required Languages (Brief description of the language skills needed to perform the job)

Excellent level of English, written and spoken

Travel / Rotation Requirements (Brief description of any travel or rotation requirements)

International and domestic travel up to 25% or as required.

This job description outlines the types of responsibilities the incumbent is required to perform.

The incumbent may be required to perform job related tasks other than those specifically presented in this job description.

This job description is subject to regular review.

International SOS is an equal opportunity employer and does not discriminate against employees or job applicants on the basis of race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state and local laws.