Hospital Network Management Senior Specialist

Job Description Summary
The incumbent is responsible for supporting the governance and quality management of empaneled medical providers, ensuring alignment with company policies and medical provider management standards. This includes contributing to the development and implementation of provider selection, evaluation, and onboarding processes, as well as conducting periodic reviews of providers engaged directly with Prudential Vietnam Assurance (PVA).
The role involves monitoring provider performance through ongoing quality assessment activities, such as audits, data analysis, and training, to ensure services are delivered in accordance with regulatory requirements, medical necessity standards, and company expectations. The incumbent also collaborates closely with medical providers and internal stakeholders to address service gaps, support continuous improvement initiatives, and facilitate discussions with providers to enhance service quality and customer experience in healthcare claims.
Job Description:
• To ensure governance of medical providers (hospitals/clinics or relevant healthcare service partners) signing agreements with PVA, including vendor selection, payment, operational coordination, and periodic due diligence in accordance with company policies.
• To execute process or service enhancements in alignment with delegated authority to address customer enquiries related to healthcare claims, acting as the Healthcare focal point connecting internal departments, agents, and medical providers to resolve service and process-related feedback.
• To execute to set up selection criteria for empaneling process and conduct quality due diligence before purposing to management level about corporation.
• To promote negotiation with provider about service agreement, scope of service, process and customer service quality.
• To execute contract and service management for medical providers throughout the contract lifecycle, including but not limited to: periodic payment, monitoring customer feedback, and identifying unusual patterns or potential fraud related to medical charges or services.
• To corporate with functional department to monitor payments and outstanding balances with medical providers.
• To report provider due diligence to management level as department requirement.
• To work and support management level arrange meeting with provider to share periodic due diligence results, to conduct site visit or audit or mystery shopping provider activities and request remediation during providing service to customer.
• To train or take part in to build up training material for providers, agency, internal department about process, service level agreement and Healthcare product.
• To perform communication and promotion to customer, internal department about updates or any changes from providers.
• To comply and perform other task according to management level; Comply policy and regulatory; Monitor, report, and storage documents.
1. Network Operations & Coordination
• Execute day-to-day operations of hospital and clinic network within the Direct Billing ecosystem, ensuring adherence to claims submission processes, workflows, and service standards.
• Act as the operational focal point for medical providers, supporting communication, issue resolution, and process alignment.
• Support provider onboarding activities, including validation of operational readiness and compliance with requirements.
2. Provider Performance & Claims Coordination
• Monitor provider performance indicators (e.g. TAT, accuracy, rejection/dispute cases) and escalate operational gaps or issues.
• Coordinate closely with Claims teams to ensure efficient end-to-end claims processing and resolve provider-related issues.
• Identify discrepancies, inefficiencies, or unusual patterns, including potential fraud or abuse, for further review.
3. Quality Assurance & Operational Improvement
• Support provider review, audit, or site visit activities, and follow up on corrective actions to improve service quality.
• Contribute to process standardization and workflow optimization initiatives.
• Support digital and automation initiatives related to Direct Billing operations and claims workflows.
Job Accountability / Trách nhiệm chính:
• The incumbent is responsible for supporting the development and implementation of the medical provider empaneling process, including identifying potential providers and coordinating negotiations for service agreements. This role ensures effective governance and quality management of medical provider services by establishing relevant processes, evaluation criteria, monitoring performance, and recommending remediation actions where necessary. The incumbent also participates in collaborative initiatives with medical providers to enhance service quality and customer experience in healthcare claims.