Senior Claims Specialist

To drive implementation of the business operating model across the organization processing centres.

**Minimum Requirements**
- NQF 7 (bachelor’s degree) related qualification.
- Business qualification advantageous.
- Relevant 8 -10 years’ experience in the claims administration environment of which 3 years must have been on management level.
- Experience in healthcare or insurance administration 3- 5 years
- Knowledge of claims management, clinical protocols, systems, methods, processes standards and administration.
- Data and analytical, communication, leadership, managerial and organizational skills.
- Skilled in critical thinking, creativity in resolving unique and challenging business problems.
- Understanding of injury assessment, collating and synthesis of clinical reports and linking it to the claim submitted
- Ability to do long-term planning, to create and manage budgets.
- Excellent communication skills.
- MVA legislation knowledge or Insurance claims administration advantageous.

**Outputs**:

- Prepare and present management information and reports as required.
- Establish and maintain constructive and effective internal and external relationships with all key stakeholders and partners to ensure achievement of business objective.
- Develop and maintain ways of work with other functional areas to ensure a coordinated approach in delivering business initiatives and requirements.
- Build and maintain healthy and transparent relationships and rapport with internal and external stakeholders.
- Provide sound advice on all escalated claims process and system related queries. Ensure proper planning and allocation of consistent workload within the business unit.
- Monitor performance of teams against planned activities.
- Identify and ensure sufficient training and development of employees within the business unit.
- Provide ongoing support and coaching for employees.
- Ensure that all employees have entered into performance contracts/agreements within the business unit.
- Conduct periodic employee’s performance reviews and assessments.
- Ownership of the internal clinical authorisation system rules
- and functionality.
- Subject matter expert on claims and billing rules as well as identification, implementation and automation all of hospital claims billing rules.
- Development and automation of clinical protocols and rules.
- Identify and implement any operational efficiency for claims, preauthorisation, case management, clinical protocol unit, risk management and the product development areas.
- Ownership of business process for authorisations and claims stream (reviewing, documentation and sign off).
- Ensure data integrity across the merits department and consistency with other sources.
- Ensure monthly and quarterly claims related reports are created with an appropriate supporting analysis to identify any matters important for external commentary and for internal understanding of performance.
- Drive standardisation and re-engineering of current claims processes to enable them for process automation, digital initiatives, system deployments and new processes in line with new operating model.
- Promote and develop a continuous improvement culture for claims processes across the organization.
- Manage the implementation of automated processes of direct and indirect claims handling procedures and risk management processes that will enable a smooth claims process and foster transparency for the end user.
- Ensure that claims merits are thoroughly assessed, and determination is based on accurate information.
- Liaise with other departments to identify improvements in claims process and procedure.
- Lead the effective and efficient provisioning of actuarial support and advice to the organization business.
- Manage the implementation of a successful claims mediation process to minimize litigation of a claim.
- Ensure claims activities at a high level, comply with organisational requirements for quality management, legal stipulations, and general duty of care.
- Ensure claims are measured against operational risk systems and processes to govern threshold breaches.
- Identification and management of claims trend