Manager – Ring Fence Operations

Overview

A. Ring Fence Governance & Account Ownership

• Lead end-to-end accountability for the RF account as single point of contact for performance, delivery and client relationship.
• Maintain ring-fence integrity through physical, system and data segregation from other NHS accounts.
• Govern user access, system permissions and information barriers to restrict RF data to authorized ring-fenced staff.
• Liaise with the RF client team on operations, escalations, governance forums and Joint Operating Committee (JOC) meetings.
• Operate the tiered governance cadence — daily huddle, weekly ops, monthly business and quarterly strategic reviews — with named counterparts at each tier.

B. RingFence Brand, Values & Service Culture

• Translate RF values and brand promise into observable team behaviors, scripts and service rituals across every touchpoint.
• Define and operationalize a RF Service DNA — service standards, language, tone and recovery behaviors — to train, measure and coach the team.
• Embed personalization through end-to-end case ownership: each member journey, especially complex / chronic / high value, carries a named owner from intake to post-event follow-up.
• Run cultural induction and re-induction for new joiners and tenured staff so the RF identity is consistently internalized.
• Use NPS / CSAT, complaint themes and provider feedback to shape coaching, recognition and corrective actions; target 5–10% year-on-year output lift.
• Run a monthly recognition framework — agreed with RF — to celebrate team members who live the values in service.

C. Provider Engagement, Training & Sensitization

• Own the RF provider engagement programme covering product, benefits, clinical protocols, pre-auth standards and member-experience expectations.
• Run at least 4 provider training waves per year, starting with top-utilization facilities and cascading across the network, with attendance, completion and assessment tracked.
• Conduct planned onsite provider visits — minimum 2 per week, priority providers at least quarterly — covering reception, billing, doctors-in-charge and ops leads.
• Sensitize provider teams to the differentiated RF service standard for greeting, triage, communication and servicing of members.
• Maintain a provider engagement tracker — visits, training, issues, actions, closure — with quarterly reports to RF and the NNHS Network team.
• Act as escalation route for RF specific provider matters; resolve within shift and loop root causes back into training and the next visit.
• Partner with the NNHS Network team on contracting, fee schedule and benefit alignment issues raised through provider engagement, preserving ring-fence boundaries.

D. Process Customization & Service Differentiation

• Customize SOPs, scripts and exception-handling for RF — not generic NNHS playbooks — and refresh quarterly or on any benefit / policy change.
• Operate a concierge track for complex, high-value and chronic RF cases with senior clinical oversight, faster TATs and dedicated channels.
• Differentiate RF communications across pre-auth, pharmacy, reimbursement and claims — SMS, email, IVR, app — so the brand identity is recognizable in every message.
• Maintain an SOP library with dual NNHS / RF sign-off on member-impacting changes; ensure version control and assessed team rollout.
• Operate the delegated authority matrix across clinical, financial and network decisions; ensure correct application and auditable, defensible decisioning.
• Maintain a customization backlog drawn from complaints, provider feedback, payer audits and ops data, with quarterly delivery commitments.

E. Operational Performance, KPIs & SLAs

• Achieve daily / monthly KPIs and contractual SLAs at minimum 95% adherence; review deviations with Supervisors / Assistant Managers and drive corrective action.
• Hold end-to-end accountability for RF OP / IP pre-authorizations, Direct Billing, Reimbursement and case management.
• Operate a joint scorecard covering SLA, quality, experience and financial metrics — co-owned with RF at agreed cadence.
• Conduct daily pipeline reviews on queues, ageing and TAT exceptions; agree and implement same-shift mitigation.
• Ensure TAT adherence for RF claims and pre-approvals and optimal utilization of ring-fenced resources.
• Publish dashboards with RF co-owned definitions and thresholds covering KPIs, productivity, quality, TAT and backlog — with mitigation plans where needed.

F. Stakeholder Management & Cross-Functional Coordination

• Partner with PBM, Direct Billing and Payer-Provider Support to keep RF operations within regulatory and contractual SLAs.
• Coordinate with PMD, CCD, QA, UM, CRM, IT, Finance, Networks and Marketing while preserving ring-fence boundaries.
• Manage provider escalations, member grievances and broker / corporate queries with same-shift / agreed-timeline resolution.
• Handle F providers and member queries by phone, email and tickets to a consistent service standard.

G. Claims Adjudication & Medical Decisioning

• Adjudicate RF Direct Billing and Reimbursement claims — initial, resubmission, reconciliation — in line with coverage, coding / billing guidelines and medical necessity.
• Review high-cost and complex cases independently; sign off as per authority matrix.
• Maintain full command of RF policies — benefit limits, exclusions, network tiers, co-insurance and co-pay — across all groups.
• Assess claims and pre-auth requests with evidence-based medical decisioning, applying international protocols and local / regional norms.
• Assess eligibility within UAE regulatory frameworks (DOH, MOH, DHA) and RF policy boundaries, ensuring full compliance.
• Investigate and respond to internal queries / complaints on medical necessity and guide team members on RF-specific calls.

H. Cost Containment, FWA & Utilization Management

• Control claims cost through all permissible means; surface FWA trends with the FWA team and escalate prevention actions to stakeholders.
• Mitigate future TPA expenses and manage liabilities jointly with RF providers and the payer.
• Lead RF UM — track utilization, build and activate mitigation plans, and flag member abuse, benefit changes or restricted network access for high-utilization providers.

I. SOPs, Audit, Compliance & Quality

• Refresh RF SOPs and KPIs quarterly to reflect market shifts, regulatory changes and SLA updates.
• Review internal audit findings; raise major deviations with team members and track CAPAs to closure.
• Review RF payer audit files and provide feedback within agreed timelines.
• Support reconciliation activities with Finance and the payer as required.
• Review upheld member / provider complaints monthly; run root-cause analysis and trigger technical or training fixes to prevent recurrence.
• Hold the team to 99% procedural and 99% financial accuracy: track improvements and report quality outcomes to the Senior Manager.

J. People Management & Capability Building

• Mentor Supervisors / Assistant Managers with monthly one-on-one counselling sessions.
• Set annual role-level objectives with weightages and track progress quarterly.
• Align with the Senior Manager on performance reviews and leave planning to maintain shift coverage and KPIs.
• Coach team members monthly to lift output by 5–10%; address grievances and uphold fairness across the team.
• Run training plans for new and existing staff on RF pre-auth and claims protocols; host at least 5 internal sessions per year covering Policy, Medical, Coding and Service Culture, signed off by the Senior Manager.
• Complete 10–15 CMEs per year on medical and insurance topics relevant to the role.

K. Technology, Payer Integration & Continuous Improvement

• Lead testing and rollout of system enhancements — configuration, benefit set-up and rule-engine changes — on RF modules.
• Operate and govern RF payer integration — direct read-access to claims, auth, pharmacy and UM data — with access controls, data accuracy and timely dashboard refresh.
• Drive the joint data / API integration roadmap with IT and the RF client team, with milestone tracking and quarterly reporting.
• Escalate software issues to the reporting manager and IT POC and drive to closure with documentation.
• Identify automation, digitization and process re-engineering opportunities to lift cost efficiency, TAT and member / provider experience.

3. Knowledge, Skills And Experience

• University degree in any discipline of Medical / Para-medical specialization — BDS, MBBS, MD, BAMS, BHMS — from a reputable university.
• Minimum 7–10 years in the Insurance / TPA industry, with at least 3–5 years managing claims and pre-authorization teams.
• Prior experience managing a ring-fenced or dedicated client account end-to-end is strongly preferred.