Claims Technical Specialist

2 weeks ago

Durban, South Africa Momentum Metropolitan Holdings Full time

-Introduction

Momentum 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 Purpose

To provide high operational quality and technical support to ensuring that the organisational processes are maintained.
Requirements
- Grade 12
- Relevant tertiary qualification will be advantageous
- Minimum 3-5 years’ experience in the Medical Aid Industry
- Minimum 3 years’ experience within the specialist area of function, such as claims assessing, premium management, membership etc. as applicable
- Proven Client relationship Management, Time management and written and verbal communication skills
- Exceptional understanding of the Healthcare Industry with specific focus on Scheme rules as per the operational area (e.g. claims, membership, premiums etc.)
- Thorough understanding /proficiency of the operational system/s (i.e. Oracle 1 or 2, reports, web, interfacing processes.
- Excellent understanding of the interrelations of the functional areas with internal and external parties/role players Advanced computer literacy in MS Office
- Ability to work in a pressurized environment
- A high focus on customer satisfaction
- Transfer of knowledge to team and other business areas internal and external
- Ability to work independently with mínimal supervision
- Be able to interact at all levels of the organisation internally and externally Be able to work under pressure managing strict deadlines and SLA, and be available after hours, weekends nights and all holidays to ensure delivery monitoring and maintenance functions
Duties & Responsibilities
- Implement scheme benefit rules to the claims Administration system both backend (configuration items) and front end (user interface),
- Implement and maintain yearly and ad-hoc scheme pricing files and associated system configuration tables, including the Error Masterfile.
- Maintain the Doctor Table and ensure that the PCNS data records are aligned,
- Ensure that the system enables the delivery of the contractual SLA per operational areas
- Receive interpret and identify the requirements of the client benefits, rules, mandates, requests to facilitate the above
- Improve efficiencies of the claims administration system
- Ensure claims integration with other internal functional areas such as membership, premium management, finance, forensics, ex gratia, client services etc.
- Ensure claims integration with external parties of the client scheme for claims processing, managed health care
- Interact with external stake holders of the Scheme/ Client such as, the Scheme, Auditors, Actuaries, Business partners, Managed care organisations, industry role players etc. to ensure effective claims functioning at all levels from implementation to day to day operations at a technical level.
- Facilitate business process between external parties with operational areas.
- Interact with internal business parties such as IT, Forensics, membership, Audit to enable their operations as it relates business operations
- Facilitate and or resolve high level queries, requests and complaints that operational areas are not able to resolve
- Provide reporting on specific objectives as set out from time to time
- Manage day to day deliverables within the Technical specialist area related to system maintenance, system functional reviews, query management, project status reporting etc.
- Perform auditable QA and sign off on projects implemented
- Making smart recommendations on how to improve the effectiveness, efficiency and delivery of services through the use of technology and technical methods and methodologies.
- Recognising opportunities for business change, communicates them persuasively to appropriate stakeholders.
- Leads technical assignments which involve specialists from various disciplines, and takes responsibility for the quality, timely delivery and appropriateness of the team’s recommendations.
- Participates in the development of and/or review of standards, documentation and methods of working in the relevant area of expertise.
- Performs preliminary studies, general systems specifications and detailed systems specifications.
- Assists others in resolving complex technical problems and investigating the root cause of problems and recommends smart (specific, measurable, achievable, realistic and timely) solutions.
- Coaches and leads others in acquiring knowledge, and provides expert advice. Facilitates workshops, as may be required/requested for internal and external needs
Competencies
- Understands how the business operates, what the key issues and risks are that drives business success; and how they impact on the commercial viability of potential ventures and the prof

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