Job Description

Job Summary Key Performance Areas

• Claims:
• Clinical Assessment of Claims
• Assess, process, and reconcile all claims received within defined SLA
• Paid out claims within defined SLA

• Pre-Auth:
• Manage pre-authorisation cases
• Resolve escalated customer queries and complaints
• Develop and motivate staff
• Perform general administration duties
• Financials

Key Tasks

• CLAIMS

Clinical Assessment of Claims

• Assess the clinical appropriateness and necessity of claims based on clinical guidelines and protocols within policy limits

Assess, process and reconcile all claims received within defined SLA

• Implement Cost management
• Review trends and variances
• Make necessary changes to improve performance
• Oversee that the systems are used effectively, to improve accuracy and minimise errors
• Handle complex complaints and difficult customers
• Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning
• Track performance, based on business requirements
• Up skill the team to resolve complaints quickly and efficiently
• Apply sound financial principles and processes to the business
• Manage profitability, compliance and continued growth
• Take responsibility for actions, projects, department and people
• Take initiative and work under own direction
• Initiate and generate activity and introduce changes into work processes
• Make quick, clear decisions which may include tough choices and considered risk
• Use appropriate templates and channels to report progress on a weekly and monthly basis.
• Adhere to deadlines
• Maintain high accuracy and quality
• Create and execute a claims strategy
• Manage client relationships and expectations as well as build collaborative and sustainable client relationships
• Oversee the delivery of excellent claims service to internal and external clients
• Establish clients needs and provide appropriate solutions
• Put best practice processes in place and implement compliance thereof
• Negotiate and authorise large and complex claims in line with the mandates provided
• Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff
• Mentor and coach team members
• Delegate appropriate mandates to staff
• Manage subordinates daily
• Resolve all IR and staff welfare issues
• Train and mentor, all staff
• Oversee career development of staff

Pay out claims within defined SLA

• Maintain good co-operation with internal and external stakeholders and provide necessary information and reports as per requirements
• Coordinate, distribute and follow up on workload

PRE-AUTH
Manage pre-authorisation cases

• Advise on all rules and related information for campaigns and interventions to the team.
• Identify opportunities to improve and expand product and service offerings.
• Manage areas of critical compliance.
• Maintain service, quality, and desired outputs by enforcement of compliance to tactical policies, procedures and standards.
• Participate in the creation of new standards, control systems and procedures to maintain service delivery.

Resolve escalated customer queries and complaints.

• Manage the risk that no misrepresentation of the product is allowed.
• Provide feedback to customers on matters resolved.

Develop and motivate staff.

• Implement Cost management.
• Review trends and variances.
• Make necessary changes to improve performance.
• Oversee that the systems are used effectively, to improve accuracy and minimise errors.
• Handle complex complaints and difficult customers.
• Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning.
• Track performance, based on business requirements.
• Up skill the team to resolve complaints quickly and efficiently
• Apply sound financial principles and processes to the business
• Manage profitability, compliance and continued growth
• Take responsibility for actions, projects, department and people
• Take initiative and work under own direction
• Initiate and generate activity and introduce changes into work processes
• Make quick, clear decisions which may include tough choices and considered risk
• Use appropriate templates and channels to report progress on a weekly and monthly basis
• Adhere to deadlines
• Maintain high accuracy and quality
• Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff
• Mentor and coach team members
• Delegate appropriate mandates to staff
• Manage subordinates daily
• Resolve all IR and staff welfare issues
• Train and mentor, all staff
• Oversee career development of staff

Perform general administration duties.

• Develop roster in line with operational plans and or schedules
• Generate reports on performance of the department
• Prepare and submit periodic reports

Financials

• Load payment Files
• Process upfront payments to providers

Essential Qualifications

• Matric
• Business Degree (e.g. B. Com, B.Sc. etc)
• FAIS Compliant (RE1 and RE5)
• Clinical Qualification
• SANC Registration

Desirable Qualifications

• Accounting or Finance qualification

• Pre-authorisation and case management or relevant managed healthcare experience
• Microsoft Excel Intermediate or Advanced Certificate

Essential Experience

• 3 years management experience within the financial services environment
• 5 years experience in the insurance industry or similar environment e.g. Healthcare
• Experience in the implementation of business change and optimisation projects
• Insurance and/or medical aid experience

Desirable Experience

• 2 years insurance industry experience

Knowledge and Skills

• Knowledge of claims processing, approval
• Knowledge of business policies, processes and procedures, legal compliance
• Expert technical knowledge involving coverage and contract interpretation
• Liability issues analysis experience
• Claim litigation management skills
• Experience in mediation/arbitration and dispute resolution management
• Numerical skills
• Negotiation and persuasion skills
• Networking skills
• Business Acumen
• Customer Centric
• Relationship building skills
• Excellent organisational skills
• Excellent written and communication skills
• Time management skills
• Excellent interpersonal skills
• Client relationship-building skills
• Directing and Controlling skills
• Staffing skills

Attributes

• High degree of commitment
• Motivated
• Deadline orientated.
• Honest, Hardworking and Humble

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