Talent Pool: Technical Specialist

Role Purpose

The role is responsible for the technical support, maintenance, enhancement, integrity and governance of claims backend functionality that support accurate claims adjudication.

Requirements

Qualifications

• Matric / Grade 12 - Essential
• Relevant certification or training in medical aid administration, healthcare funding, claims processing, data management or systems support. - Essential

Knowledge

• Solid understanding of the medical aid industry's processes, regulations, and dynamics.
• Claims processes, procedures and operating systems
• Claims legislation and Scheme rules
• Claims processing methods and techniques
• Training techniques and methods
• Deep understanding of the medical aid industry, specifically claims procedures, best practices and legislation.
• Familiarity with logging of IT help-desk calls
• Familiar with audit requirements
• Knowledge of insurance risk assessment and mitigation strategies
• Familiarity with claims management software and databases

Experience

• 3 to 5 years’ experience in a medical aid, healthcare funding, managed care or claims administration environment. Essential
• 3 to 5 years’ experience in provider and/or pricing masterfile maintenance Desirable
• Experience in claims operations support or claims systems support. Desirable
• Sound understanding of medical aid claims processing, provider structures and tariff application.Desirable
• Strong analytical, problem-solving and data validation skills.
• High attention to detail and strong control orientation.
• Proficiency in Excel and relevant operational or claims systems.

Duties and Responsibilities

PROCESS

• Review and rectify claims on the Claims Control Reports on all claims systems and identify root causes on rework items and ways to correct the business processes and systems.
• Identify training needs of employees related to all claims processes and liaise with Line Managers to arrange training on all claims processes and systems within the business.
• Liaison with System Admin Department and external stakeholders with regards to claim issues and improve claims processes within the business.
• Maintain and enhance claims business processes and document on the central archive repository platform to be easily accessible to internal stakeholders.
• Develop and implement strategies to efficiently and effectively resolve claims whilst minimising costs and maximising client satisfaction within the business.
• Assess both Electronic Data Interchange (EDI) and paper claims to identify potential risks and how these could be addressed and prevented.
• Provide quality feedback to email investigations, escalated complaints and other department queries and ensure all correspondence are archived and dealt with timeously by the customer service and claims team.
• Encourage an in-depth understanding of various claims processing methods systems and processes to all employees and internal stakeholders within the business.
• Provide high-quality business operation and technical support to maintain organisational processes, ensuring smooth operations.
• Apply innovative/creative thinking by identifying gaps, proposing solutions/enhancements, and presenting them to maximise process efficiency
• Participate in external and internal audits, contributing to compliance and process improvement efforts.
• Assist in the drafting and maintenance of Quality Assurance Frameworks, ensuring they are up-to-date and aligned with requirements.
• Build data models based on stakeholder requirements to support data-driven decision-making.
• Collaborate with stakeholders to define reporting requirements and timeframes, delivering accurate reports as per agreed-upon standards.
• Compile and obtain appropriate sign-off for stakeholder reports, operational reports, and administrative reports to support decision-making.
• Provide technical assistance to QA and Governance staff, offering expertise and support as needed.
• Maintain an internal data and reporting repository for the Governance and Quality Assurance department, ensuring accessibility and data integrity.

CLIENT

• Build and maintain relationships with clients, internal and external stakeholders.
• Deliver on service level agreements applicable to clients, 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 area of responsibility.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
• Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

PEOPLE

• Build strong relationships through providing specialist know-how to others and expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
• Take ownership for driving career development

FINANCE

• Identify solutions to enhance cost effectiveness and increase operational efficiency.
• Implement and provide input into governance processes, systems and legislation within area of specialisation.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes
• Provide input into the risk identification processes development and communicate recommendations in the appropriate forum

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