Job Ref #: OP-211
Industry: Insurance
Job Type: Permanent
Positions Available: 1

Job Description

Main purpose of the Job

To ensure that all Gap claims are accurately captured into the iMed system.

Position Specific Outputs

 

• Duplicate check claims received, and process claims and emails according to processes.
• Capture all claims received in accordance with relevant legislation and processes.
• Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
• Providing coding review and resolution on call centre queries
• Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
• Communicate with Stake holders
• Maintain clinical documents and processes
• Review and action QA reports and provide corrective actioning
• Assist with training and sharing of knowledge within the team and clients
• Assist on the various Call centres
• Assist with call centre call backs.
• Review and assess gap claims.
• Verify documentation and ensure all required information is completed.
• Communicate with clients and stakeholders to gather necessary information.
• Process claims efficiently and accurately.
• Maintain detailed records of claims and assessments.
• Collaborate with other departments.
• Assist with departmental Adhoc duties where required.

 

Operating Model:

 

• Conduct accurate and effective intervention/reconciliation of administration on all allocated claims.
• Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement.
• Continuously apply relevant rules.
• Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims.
• Rectify incorrect information on claims and escalate where required.
• Reconcile claims where required and communicate outcome.
• Ensure correct payments to vendor or member.
• Meet delivery objectives through working with other team members within and linked to the department / project.
• Resolve operational performance variations and problems and escalate unresolved issues to higher levels.
• Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery.

 

Operational Implementation of Strategy:

 

• Keep up to date with operational changes implemented in response to important external influences
• Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
• Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement

 

Operational Leadership:

 

• Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
• Engage in development, coaching and mentoring
• Support transformation through valuing diversity
• Behave in alignment with the Afrocentric values

 

Stakeholder Management:

 

• Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies.
• Identify, investigate, respond to and refer IT assessing queries appropriately.
• Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved.
• Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in.

 

Job Requirements

Minimum Academic, Professional Qualifications & Experience required for this position

• Grade 12 with English and a second language
• RE5(Advantageous)
• 3 years relevent healthcare industry, short term insurance and credit data capturing and claims processing experience.
• 1 Year Gap cover experience.

Competency Requirements

 

Knowledge:

 

• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedures
• Knowledge of scheme rules and contractual negotiations

Skill:

• Problem solving and decision making skills
• Business Writing Skills
• Communication Skills
• Computer Technology Skills
• Task Management
• Adobe Creative Suite
• Data modelling and evaluation
• Attention to Accuracy and Detail
• Numerical Ability
• Customer Focus
• Multitasking
• Strong analytical and problem solving skills
• Proficiency in Microsoft Office Suite
• Relevant systems knowledge and application