Claims Manager

2 months ago

Sandton, South Africa Oneplan Underwriting Managers (Pty) Ltd. Full time

**Job Summary**:
The Role as Claims Manager will be responsible for overseeing the administration and authorisations of claims of daily administrative operations and managing the insurance processes for client transactions for approvals of procedures through veterinary clinics. This role involves liaising with veterinary clinics addressing clients’ queries and concerns, ensuring compliance with health regulations, streamlining administrative processes, and working closely with clinical teams to support client / patient care. The manager also plays a critical role managing the administration team, enhancing operational efficiency and ensuring timely client / patient access to necessary services.

**Duties & Responsibilities**:

- **Authorisation Management**:

- Oversee the entire insurance authorisation process for veterinary hospital services, including surgeries, treatments, and diagnostic procedures.
- Overseeing and ensuring all necessary documentation, including medical records, is submitted accurately and in a timely manner.
- Ensuring productivity and execution of authorisations are done timeously.
- Resolve issues with denied claims, claim queries or delayed authorisations.
- **Administrative Operations**:

- Supervise administrative staff responsible for managing patient / client registrations, assessment of claims, and other clerical functions.
- Implement efficient administrative workflows and ensure proper record-keeping.
- Collaborate with clinical departments to ensure smooth coordination between administrative and administrative functions from suppliers.
- **Financial Oversight**:

- Collaborate with the finance department to track and monitor administration and authorisations for payment processing.
- Oversee cost estimates for claims and review concerns related to the product policies for approval of claims.
- **Team Leadership**:

- Lead and develop a team of administrative and authorisation staff, providing training and mentoring as needed.
- Set performance goals for the team and ensure they meet the established standards.
- Conduct performance reviews and provide ongoing feedback for team improvement.
- **Compliance & Reporting**:

- Ensure adherence to all legal, regulatory, and accreditation standards related to veterinary hospital administration claims and pet insurance practices.
- Prepare regular reports on authorisations, denials, and pending claims for senior management.
- Maintain records of all authorizations, including dates, approvals, denials, and appeals.
- Reporting may be required on multiple projects and ensuring delivery on expected timelines / targets set.

**Key Performance Indicators (KPIs)**:

- Authorisation Approval Rate:

- Percentage of authorization requests approved on the first submission.
- Average time taken to secure approvals from insurance companies.
- Claims Denial Resolution:

- Rate of resolved denied claims.
- Time taken to appeal, and resolve denied claims.
- Client Satisfaction:

- Patient feedback on administrative processes, particularly regarding billing and insurance communication.
- Timeliness in addressing patient concerns and questions.
- Operational Efficiency:

- Reduction in administrative processing times for admissions and discharges.
- Efficiency in coordinating patient authorizations with clinical schedules.
- Team Performance:

- Achievement of team-based goals (e.g., meeting deadlines, accuracy of submissions).
- Staff retention and satisfaction within the administrative team.
- Compliance Adherence:

- Zero incidents of non-compliance with health, safety, and insurance regulations.
- Number of audits passed with mínimal issues.

**Key requirements of the role**:
**Education**:

- Bachelor’s degree in business financial administration (BCom), Business Management Degree / Qualification (NQF5) and or Bachelor of science (BSc) or a related field, would be preferable and advantageous.
- Medical workplace experience working within a veterinary clinic / hospital or medical centre for 2-3 years.
- Qualified Veterinary Nurse would be advantageous and should be very familiar with the veterinary clinic services and practices.
- Additional certifications in pet healthcare management or insurance billing are a plus.

**Experience**:

- 5+ years of experience in pet healthcare administration, including at least 2 years in an insurance authorisation or billing role.
- Proven experience managing a team within a pet healthcare setting.
- In-depth knowledge of pet health insurance policies, reimbursement processes, and authorization procedures.
- Familiarity with veterinary service, pet hospital administrative processes and insurance claim systems.
- Proficient in office management software and Microsoft Office Suite.
- Strong organizational and leadership skills.
- Excellent communication and interpersonal abilities.
- Ability to multitask and prioritize effectively in a fast-paced environment.
- Problem-solving skills and attention to detail.

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