Clinical Risk Consultant
3 days ago
**Purpose of the Role**:
Clinical Risk Management by underwriting, authorisation according to protocol, case management and claim auditing. Provide support and education to clients/providers relating to claims and claim queries. Project a professional company image through customer/provider interaction. Provide support and education to clients and appropriate vendors/providers relating to claims/clinical queries, processes, and the policy. Project a professional company image through omni channel interaction.
**Key Responsibilities**:
**Claims Assessing and Claims Authorisatio**n
- Authorization of Hospital (primarily), Day-to-day and/or all related claims as per policy terms and conditions and standard protocol.
- Working 12 hour shifts inclusive of weekends/public holidays/nights as per scheduling (Inherent requirement of the role).
- Answer phones and respond to customer requests within the determined SLA.
- Explain products and update customer details in computer system.
- Follow and adhere to claims/company processes, procedures, and protocol.
- Recognize, document, and alert the supervisor of trends in customer calls/claims.
- Recommend process improvements.
- Focus on first call resolution as far as possible.
- Transfer customer calls to appropriate staff/department, where necessary.
- Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim.
- Daily reporting and updates: Ensure daily stats are updated and sent to supervisor/ manager at the end of each day. This includes submission of all relevant reports, paperwork and updates on all claims activity as directed, in a timeous manner.
- Assessing of claims according to standard operating procedure and company protocols.
- Improve client service experience, create engaged clients, and facilitate organic growth.
- Manages tasks allocated through omni-channel platforms.
- Handle complex and escalated client service issues.
- Build/maintain rapid channel of communication to client in case of service-related issues and events.
- Represent the “Voice of the Customer”.
- Create a culture of Customer/Client Centricity.
- Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Supervisor.
- Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
- Leverage team success to drive all initiatives and experiences with clients.
- Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
- Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client’s queries from end-to-end to ensure a world class client service experience.
- Support cross functional work areas targeted to resolve issues raised by clients.
- Proactively gather client feedback to optimize client experience.
**Underwriting**
- Underwriting according to protocol and to ensure effective risk management.
- Accurately Underwriting of new dependents, underwriting according to protocol and to ensure effective risk management.
**Additional tasks**
- Be available and willing to assist with any additional tasks and projects, as required by the department.
- Reviewing/capturing/assessing of specialized claims including but not limited to disability, dread, death and repatriation.
- Reviewing clinical guidelines/SOPs as required.
**Claims Queries**
- Identify, research, and resolve customer issues.
- Follow-up on customer enquiries not immediately resolved, within determined SLA’s.
- Educate clients on claims process as required.
**Quality, Consistency and Compliance**
- Maintain QA call metrics as defined by the business.
- Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
- Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
- Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
- Maintain QA call metrics as defined by the business.
- Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
- Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
- Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
- Ensure quality assurance standards are met as per company guidelines.
- Ensure adherence to all relevant legislation and regulations as set out by the Company, Regulatory Board, and the Financial Services industry.
**Work collaboratively**
- Build a culture of respect and understanding across the organisation.
- Recognise outcomes which resulted from effective collaboration between teams.
- Build cooperation and overcome barriers to
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