Job Description

Closing Date 2024/07/11
Reference Number MMH240628-3
Job Title Reporting And Audit Specialist
Position Type Permanent
Role Family Risk
Cluster Health Solutions
Remote Opportunity Some of the time
Location - Country South Africa
Location - Province Western Cape
Location - Town / City Cape Town
IntroductionMomentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities
Role PurposeTo provide business with operational business intelligence including analytics, metrics, and reporting that will empower the business and client to make informed decisions aligned to the claims strategy. To manage audits end-to-end from initiation to conclusion including driving the business areas to conclude closure of findings.
Requirements

• Matric
• Audit or Reporting qualification is advantageous.
• Min 5 years relevant experience within the healthcare claims and/or medical aid industry essential.
• Relevant reporting and auditing such as:
• Experience in Computer-assisted audit techniques (CAATs).
• Knowledge of scheme rules including managed care, PMB and underwriting protocols, and processes.
• Detailed knowledge of the claims operating system and ability to navigate and understand various backend screens for authorizations, HIV, tariffs, benefit rules, etc.
• Solid knowledge and understanding of GEMS benefits.
• Extensive understanding of the SPN external business partners' claims integration methods and processes essential.
• A solid understanding of Membership, Client services, Forensics, Fraud waste and abuse, finance, Clinical audit as well as masterfiles for Tariff, Rules, Doctor/service providers, etc. within the organization in relation to claims.
• Substantial knowledge/experience in data analytics and reporting advantageous.
• Understanding of healthcare/medical aid industry administration essential.

Duties & ResponsibilitiesINTERNAL PROCESS

• Develop, manage, and review reports and dashboards that provide meaningful insights on claims operations reporting and audits.
• Produce and interpret numerical reports in order to provide insight into the organization's data and drive strategy.
• Provide insights to manage and mitigate high risk within the department related to reporting and audits outcomes.
• Manage the process of collecting data from various sources to develop reports.
• Verify data for quality and accuracy in reporting.
• Ensure that reports are consistent and standardized for all business units for ease of reference.
• Drive efficiencies in reporting and auditing.
• Identify root causes on items identified.
• Identify GAPS in business processes and or ensure those audit findings are addressed, completed, and adhered to by the relevant departments.
• Maintain and enhance business processes.
• Assist the department in developing strategies and recommend relevant solutions to address any findings for closure.
• Produce standard and ad hoc reports that are delivered to the scheme and other clients/areas.
• Review information of these reports for any potential anomalies or variances that may require further investigation and interpretation.
• Be able to request, extract, and review claims data from the data warehouse, cubes for investigation and analysis.
• Ability to create standard operating procedures (SOPs) for business processes owned and managed by other departments.
• Review SOPs and determine the validity and accuracy of these SOPs and adherence to them.
• E-mail investigations escalated complaints and client service queries.
• Ensure all correspondence is archived and dealt with timeously.
• Ensure audit requests are completed and manage client expectations.
• Assisting with claims-specific projects when required.
• Assessing both EDI and paper claims.
• Providing quality written feedback to claims queries and ad-hoc requests.
• In-depth understanding of various claims processing methods.

CLIENT SERVICES

• Provide authoritative, expertise and advice to clients and stakeholders.
• Liaising with internal and external auditors and/or partners.
• Identify training needs.
• Manage escalated queries of the business and external partners in relation to audits and reporting.
• Liaison with System Admin Department with regard to system problems when needed.
• Be able to engage professionally with senior officials including those of the client scheme, SPN partners and colleagues.
• Deal directly with internal and external auditors.
• Liaising with internal and external business partners at senior levels.
• Build and maintain relationships with clients and internal and external stakeholders.
• Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed.
• Make recommendations to improve client service and fair treatment of clients within the area of responsibility.

PEOPLE

• Develop and maintain productive and collaborative working relationships with peers and stakeholders.
• Effectively manage performance and development within the team to ensure business objectives are achieved.
• Positively influence and participate in change initiatives.
• Continuously develop own expertise in terms of professional, industry, and legislation knowledge.
• Contribute to continuous innovation through the development, sharing, and implementation of new ideas.
• Take ownership of driving career development.

FINANCE

• Contribute to the financial planning process within area.
• Identify opportunities to enhance cost-effectiveness and increase operational efficiency.
• Manage financial and other company resources under your control with due respect.
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

CompetenciesBusiness Acumen: understands how the business operates, and what the key issues and risks are that drive business success for the department and team.Client Commitment: anticipates, meets, and exceeds clients needs by creating long-lasting relationships that support the client's value proposition, support their financial wellness, and ensure client centricity.Drive for results: drive a sense of urgency, focus, accountability, agility, and execution to deliver business results.Leads change and innovation: actively leads change, does what is right for the business, and drives continuous improvement through innovation.Collaboration: prioritizes the business interests of Momentum Metropolitan and invests in the success of the group by aligning efforts across departments.Impact and influence: persuades, convinces, influences, and inspires others, both within Momentum Metropolitan and externally to win support, loyalty, and gain commitment to the purpose of Momentum Metropolitan.Self-awareness and insight: manage self and relationships with others effectively and provides perspective in difficult situations.Diversity and inclusiveness: Is sensitive to individual and cultural similarities and differences and demonstrates humility and an openness to engage people from diverse backgrounds and cultures to the mutual benefit of all parties concerned.PolicyWe are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.

Momentum Metropolitan