Manager (Pre-auth and Claims Department)

2 weeks ago

Johannesburg, South Africa National Risk Managers (Pty) Ltd Full time

A Medical Insurance company based in Benoni is looking for a Manager to Manage the Pre-Auth and Claims department. The Manager will manage the accurate and timely processing of claims within established legal and company compliance guidelines. Manage the pre-authorisation department and facilitate the process of pre-authorisation as per requests from members for procedures and admissions.

**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**

**Clinical Assessment of 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
- 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
- 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

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