Clinical Audit Clerk

-Introduction

Metropolitan is one of the oldest financial services brands in South Africa. With a 116-year legacy of serving the communities in which it operates, Metropolitan represents true empowerment in serving Africa's people through affordable financial solutions that create financial growth and security.
Role Purpose

To provide an effective and efficient service to clients by receiving, evaluating, and responding to telephonic/electronic inquiries timeously.
Requirements
- Matric
- Relevant tertiary qualifications (i.e., Customer Relationship Management, Business Management, Project Management, Operations Management) would be advantageous.
- Claims School training.
- 3 - 5 years in the medical aid industry:

- 2 - 3 years of Claims processing experience within the medical aid industry.
- 2 -3 years of query management experience.
- 2 - 3 years of client service experience.
- A good understanding of the MH systems would be an advantage.
- Good written and verbal communication.
Duties & Responsibilities
- Identify risks to the company and escalate accordingly.
- Engage in effective communication and delivery according to service levels.
- Maintaining a consistent service delivery to ensure client retention and satisfaction.
- Obtaining and maintaining broad product and industry knowledge in order to effectively and accurately respond to customer queries.
- Ensuring Service Level Agreements are met and exceeded at all times.
- Providing first-time resolution on queries of a complex nature.
- Dealing promptly with client requests in a competent, efficient, and professional manner.
- Driving and supporting effective teamwork within the department.
- Engaging in appropriate training interventions to promote own professional development.
- Ensuring to demonstrate the company's values on a daily basis.
- Recording of all queries and interactions with customers onto the workflow and reflection systems.
- To ensure the required turnaround time is met.
- To ensure that all correspondence sent out is of the highest quality.
- Interaction with the Clinical Advisors i.e. Medical Advisors, Radiologist, Pathology.
- Investigate client queries within the agreed service level and ensure that client receives timeous and accurate feedback.
- Escalate client queries to the relevant department or stakeholder via the applicable channel.
- Collaborate with relevant departments in ensuring resolution to complex queries.
- Participate and contribute to a culture that builds rewarding relationships, facilitates feedback, and provides exceptional client service.
- Scrutinize all suspected inappropriate/ irregular claims appearing on the Metropolitan Expert Tool (QES / MES), (GPs, Specialists, Allied Health, and Radiologist) and ensure appropriate processing.
- Investigate and action Adhoc written inquiries from the business units.
- Interact with the various medical advisors on an ongoing basis and coordinate the flow of queries.
- Address correspondence pertaining to investigations and follow-ups.
- Identify trends from QES/MES activities and refer Provider's Profiles to forensics for investigation.
- Provide Clinical interpretation and appropriateness of claims in accordance with Scheme Rules.
- Make recommendations to the team leader regarding new rules to be added to QES / MES rules engine.
- Identify new risk areas and make recommendations to the team leader.
- Respond to written communication and investigate queries relating to Clinical Audit Department functions.
- Liaise with Client Service, Claims, and CMS regarding correspondence queries.
- Develop and maintain productive and collaborative working relationships with peers and stakeholders.
- Positively influence and participate in change initiatives.
- Continuously develop own expertise in terms of professional, industry, Scheme, and legislation knowledge.
- Contribute to continuous innovation through the development, sharing, and implementation of new ideas.
- Take ownership of driving career development.
- Identify opportunities to enhance cost-effectiveness and increase operational efficiency.
- Manage financial and other company resources under your control with due respect.
Competencies
- Business Acumen
- Client/ Stakeholder Commitment
- Drive for Results
- Leads Change and Innovation
- Collaboration
- Impact and Influence
- Works independently
- Diversity and Inclusiveness

Policy

We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.