PBTB I Senior Manager, Provider Network Management

Prudential’s purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

The incumbent will be actively involved in expanding the network scope to include all providers, including TPAs. They will manage panel hospital performance, negotiations, and payments, as well as handle applications, empanelment, and termination of panel hospitals. Additionally, they will carry out plans for North Star initiatives such as tiering and steerage, maximize alignment with PAMB processes and requirements, work closely with the Data Analytics team, and lead a team under Provider Network Management.

The provider network management team is responsible for fostering relationships with panel hospitals through regular visits, performance reviews, and strategic initiatives with hospital management. It is also crucial that the team drives Prudential's goals and vision to the panel hospitals, including promoting the PruWay. This includes ensuring that our customer is our compass, pursuing our entrepreneurial spirit, succeeding together, respecting and caring for one another, and delivering on our commitments. Additionally, they ensure that hospital services and charges adhere to the Private Healthcare Act.

Key Responsibilities:
 

Leadership and Engagement

Lead the provider network team in executing the tiering and steerage initiative for panel hospitals and engage with internal and external stakeholders.
 

Preparation and Documentation

Prepare comprehensive reports and materials for hospital steerage negotiations, meticulously document all findings and issues identified during reviews, and ensure all panel hospitals are properly licensed and have signed agreements/contracts.

Performance Reviews and Audits: Conduct thorough performance reviews and audits on all panel hospitals to ensure the highest quality of services and ensure team members conduct audits in strict accordance with SOP.

Reporting and Presentation: Prepare and disseminate detailed performance review and audit reports, present findings and updates to the Head of Unit and HOD and ensure the preparation and dispatch of SOAs for hospitals by the team in accordance with SOP.

Collaboration and Liaison: Collaborate closely with the Head of Unit to liaise with hospital management on complaints or issues raised by clients, agents, claims assessors, or management, and handle complaints and cases reported by panel hospitals, following up until resolution

Compliance and Accuracy: Ensure panel hospital information across various channels (Corporate Website, Navigator Apps, systems, etc.) is up-to-date and accurate and identify shortfalls and service gaps between HAS and panel hospitals, providing solutions and training.

Financial Management: Accurately record all refunds received from audit reviews, collaborate with Finance and IT to ensure proper allocation of refunds to the relevant certificates, and ensure strict monitoring of all HAS payments and prompt processing within the SLA in accordance with SOP.

Qualifications and Criteria:

• Education: Bachelor’s degree in Business, Finance, Healthcare Management, Public Health, Life Sciences, Nursing or a related discipline (postgraduate qualification such as MBA/MPH is an advantage).
• Professional certifications (advantage): Insurance/claims certification (e.g., LOMA or equivalent), project management certification (e.g., PMP/PRINCE2), or relevant healthcare quality/governance training.
• Experience: 5–8 years of relevant experience in provider network management, medical claims/health operations, TPA management, hospital management, or health insurance/takaful operations; with demonstrated exposure to contract negotiation, provider performance management, and governance/compliance.
• Core knowledge / technical skills:
  • Strong understanding of medical claims and healthcare billing (e.g., diagnosis, procedures, common hospital charge drivers) and practical experience in managing A&H claims and/or utilization management.
  • Familiarity with fee benchmarks / schedules of fees (e.g., MMA schedule of fees or market equivalents) and/or package pricing and cost containment levers.
  • Experience conducting provider audits / performance reviews, issue management (including suspected fraud / FWA indicators), and closing the loop on corrective actions.
  • Ability to interpret and apply relevant regulatory requirements and internal governance/SOPs (e.g., provider licensing/credentialing, contracts, service standards).
  • Strong analytical capability; able to translate provider and claims data into insights for network strategy and stakeholder updates (advanced Excel; Power BI/analytics tools are an advantage).

• Leadership & stakeholder skills:
  • Proven ability to lead and develop a team, manage priorities, and deliver outcomes against KPIs/SLA.
  • Strong negotiation, influencing, and relationship management skills with hospitals/TPAs and internal partners (Claims, Finance, Legal, Compliance, Data/Tech, Distribution).
     

Excellent written and verbal communication; able to prepare clear papers, dashboards, and presentations for senior management/committees

Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex, race, age, ethnic origin, educational, social and cultural background, marital status, pregnancy and maternity, religion or belief, disability or part-time / fixed-term work, or any other status protected by applicable law. We encourage the same standards from our recruitment and third-party suppliers taking into account the context of grade, job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.