REPORTS TO: CEO | TEAM SIZE: 96 ( 4 Direct report , 92 indirect)
To lead the development and implementation of the strategic plans and operational objectives of the Health and Life claim business unit. Ensuring operational integrity and compliance with quality standards and applicable regulations and legislation across claims activities, thus contributing to the achievement of the company's strategic business goals, while ensuring excellent service delivery, client satisfaction and experience while ensuring sustainable profitability to the company.
Key Activities, Responsibilities and Accountabilities
• Lead to the development and refinement of the company s overall strategy and ensure that Health Claims strategic plans are developed and implemented in line with company s vision, mission and corporate objectives.
• Ensure that the strategy is translated into operational business plans for the Health Claims Division and monitor the performance and execution of those plans in order to achieve functional and corporate objectives.
• Build and lead a motivated, engaged and competent team in the Health Claims Division, by setting priorities and objectives, managing performance, and providing ongoing feedback and coaching to meet the organizational unit s challenges and goals.
• Serve as a role model to ensure employee awareness of and commitment to company vision, mission, values, fundamentals and corporate strategy.
• Manage performance, recruitment, development, and motivation of employees in order to maximize individual and functional performance, with a particular focus on the development of Saudi talent.
• Ensure training and development needs of Health Claims Division are addressed to ensure high-level of competence within the team.
• Oversee the health claims approval process to ensure it is time efficient and effective in order to maintain client satisfaction, while monitoring compliance with regulations, contractual agreements and applicable legislation.
• Oversee the health claims reconciliation activities to ensure that service providers are abiding to contractual agreements and review financial evaluation of claims to ensure cost-efficient and satisfactory settlement of claims.
• Ensure that the processing of health claims is efficient and effective to provide patients with the best health and medical coverage in the most cost effective and timely manner.
• Ensure that life claims are being settled with beneficiaries, in line with the company policies and procedures.
• Oversee and manage the reconciliation process with service providers as necessary to ensure claims are being settled in a cost-efficient manner.
• Oversee the quality control operations and establish best practice control measures to identify and detect fraud. As well as review the development of policies and procedures addressing necessary counter-measures to be undertaken in cases of fraud detection and that relevant mitigation processes are in place to minimize risk of fraud.
• Build and maintain strong relations with network management providers domestically and internationally and drive negotiations and contractual agreements to maximize market reach and optimize customer care, customer experience and cost efficiency.
• Drive continuous improvement of customer experience by ensuring that the care delivery unit effectively addresses customer inquiries and complaints in close collaboration with call centers, brokers and sales representatives.
Compliance and Dispute Settlement:
• Oversee internal and external compliance processes to ensure alignment and adherence to the regulatory requirements.
• Ensure a robust investigation process is in place to identify and address malpractice, misconduct, and fraudulent activity, provide recommendation measures when needed in line with relevant laws and regulations and ensure effective and timely reporting of incidents.
• Drive internal engagements and cooperation between various departments (underwriting, finance, etc.) to ensure alignment and to enhance synergies, contributing to improvement of efficiency and service delivery.
• Oversee the identification and sourcing of new targeted local and international network providers to expand the national, regional and international network and increase market share, customer reach and competitiveness.
• Prepare financial plans and budget for the Health Claims Division.
• Ensure, as a P&L owner of the Health Claims Division, that optimal financial results are achieved for continuous growth and sustainable profitability of the company.
• Identify areas of opportunities for continuous improvement of systems, processes and procedures taking into account leading practices, cost reduction and optimized productivity.
Policies, Systems, Processes & Procedures:
• Lead the development of integrated, coherent and leading-edge policies and procedures and ensure that key metrics are in place to monitor compliance across the Health Claims Division.
• Provide direction for the development and implementation of the health claims policies, systems, processes and procedures, identifying potential areas of improvement to ensure an efficient and effective operation.
• Ensure compliance with corporate requirements on policies and procedures within the Health Claims Division.