Claims Manager
2 days ago
-Introduction
Supervision of and responsibility for the Admed claims capturing team.
Role Purpose
Supervision of and responsibility for the Admed claims capturing team.
Requirements
- Matric
- Basic medical qualification an advantage (e.g. nursing or similar qualification)
- FAIS Fit and Proper including RE5
- At least 2 years supervisory experience
- At least 5 years medical aid claims processing and assessing experience
- At least 1 year insurance experience
- In-depth knowledge of the local health and medical schemes industry, as well as an understanding of demarcation and legislation governing the local health industry
Duties & Responsibilities
- Supervising the claims assessing team in a manner which achieves optimal productivity, including setting of productivity targets and ensuring that these are achieved by the team on a consistent basis
- Managing of daily work flows by monitoring work in claims staff queues, ensuring that claims are finalised within 10 working days of receipt and providing assistance to junior staff in respect of product, administration and benefit information
- Monitoring the claims assessing team in terms of claims service levels and turnaround times, ensuring that a high level of service is maintained when liaising with clients, brokers, companies and others
- Performance excellence management of the team including setting objectives and revision of the performance of the achievement of these objectives as required by company protocol. Where performance is not of the required standard, implementing necessary performance counselling or disciplinary processes
- Ensuring that the relevant internal claims protocols and procedures are followed by the claims assessing team including ensuring that correct procedures, tariff codes, modifiers, and benefits as detailed in doctors’ statements are applied to each claim and that all relevant documents are on file before a claim is sent through to the assessing team. Where protocol is not adhered to, ensuring that the necessary disciplinary action is undertaken
- Identifying training and development needs within the team and working with the Quality Assurance Manager to ensure that the necessary training takes place;
- Maintaining and ensuring good working relations with colleagues as well as compliance with policies and procedures of the company;
- Monthly analysis and reporting of claims data to identify trends, fraud, and possible problem areas
- Ensuring that the principles of TCF are delivered across every function performed, with a specific focus on the achievement of TCF Outcome 6 (Customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim or make a complaint).
- Detecting and acting on potential fraudulent claims
Competencies
- Ability to lead a team and ensure consistent optimal productivity from the team
- Results and solutions driven with a strong sense of responsibility and accountability
- Strong focus on client centricity and service excellence
- Strong problem solving and decision-making capability
- Ability to plan, organise, monitor and control a team’s daily, weekly and monthly operations
- Organised and focused with an eye for detail
- Resilience and ability to work under pressure
- Adaptability and self-discipline
- Excellent communication and interpersonal skills
- Computer literate
Policy
We 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.
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