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Quality Assessor

2 weeks ago

Centurion, South Africa Momentum Health Full time

**Introduction**
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**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