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Manager ( Pre-Auth and Claims Department)
2 weeks ago
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
- 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
- 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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