Quality Assessor

**Introduction**
- Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members. Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.

**Disclaimer**
- As an applicant, please verify the legitimacy of this job advert on our company career page.

**Role Purpose**

**Requirements**:
**Qualifications**:

- Valid Matric Certificate

**Knowledge**:

- Knowledge of Claims operating systems
- Multi discipline claims knowledge
- Knowledge of the NHRPL- National Health Reference Price List and SAMA- South African Medical Association tariffs
- Good knowledge of PMB at industry level as well as in house PMB- Prescribed Minimum Benefits processes
- Ability to quality assess (QA) claims holistically, and possible fraudulent trends of providers
- Identify various types of anomalies, which include high risk transactions, engage with BI to develop a criteria to extract the correct information for a report

**Experience**:

- 3-5 years Claims assessing experience, preferably in a Medical Aid industry

**Duties & Responsibilities**

**INTERNAL PROCESS**:

- Establish, maintain and monitor a complete quality assurance claims system and ensures standards are met
- Identify system error and report it to relevant stakeholders and ensure its rectified
- To Identify initiatives that will add value to the company/department
- Ensure your daily and monthly targets are met
- To work according to the Claims Framework
- To work on ad hoc task if and when it is required
- Identifying training interventions to address individual needs
- Quality checking random sample of claims and claims enquiries
- Assist with staff development by identifying trend analysis and training needs through QA
- Work with coaches and service managers and advise them of progress of staff
- Maintaining the confidentiality of sensitive information
- To facilitate and maintain open communication with other departments or stakeholders
- Provide regular reports on delivery of services against agreed service level agreements and in terms of overall customer targets
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service
- 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 and legislation knowledge
- Contribute to continuous innovation through the development, sharing and implementation of new ideas
- Take ownership for driving career development
- Identify opportunities to enhance cost effectiveness and increase operational efficiency

**CLIENT**:

- Build and maintain relationships with designated stakeholder groups (including clients & internal stakeholders)
- Deliver on service level agreements applicable to clients and internal and external stakeholders to ensure that client expectations are managed
- Make recommendations to improve client service and fair treatment of clients within the area of responsibility
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback, and provides exceptional client service
- Continuously monitor turnaround times and quality standards and resolve issues swiftly to enhance client service delivery
- Manage client query processes, ensuring queries are tracked, accurately resolved, and used as a mechanism to improve client service and business processes

**PEOPLE**:

- Build strong relationships by providing specialist know-how and leadership to others, expressing positive expectations
- Positively influence and manage change, offering specialist support where required
- Contribute to continuous innovation through the development, sharing, and implementation of new ideas and involvement of colleagues and staff
- Participate and contribute to a culture of work-centric thinking, productivity, service delivery, and quality management
- Take ownership of driving career development

**FINANCE**:

- Contribute to the development of area-specific budgets to minimise expenditure, aligning with operational plans
- Identify solutions to enhance cost-effectiveness and increase operational efficiency
- Implement and provide input into governance processes and systems within the area of specialisation
- Escalate unresolved policy and governance compliance issues via appropriate channels for investi