Configuration Specialist X 5

-Introduction

Momentum Health Solutions (MHS), an entity of Momentum Metropolitan Holdings, delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
Role Purpose

Responsible for configuring the O2 System accurately as well astimely implementation and maintenance of critical information.Ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, feeschedules, and other business requirements. Administers andmaintains the platform for all schemes and insurances that arecurrently administered by MHS to ensure that admin and Managed Care components are up to date to ensure that the MHS Schemes and Insurance products are functioning as per the design intent accuratelyand efficiently.
Requirements
- Matric or Grade 12
- Associated Degree or equivalent combination of education andexperience
- 5 to 7 years of Healthcare experience
- In-depth medical aid industry knowledge - Essential
- A good understanding of how medical aid administration operates(including and not limited to the benefit structure and medicalterminology) - Essential
- Good knowledge of file formats and reporting tools - Advantageous.
Duties & Responsibilities

Internal Process
- Analyze and interpret data to determine appropriate configuration changes.
- Accurately interprets specific Scheme benefits, contracts as well asadditional business requirements and converts these terms toconfiguration parameters.
- Validates coding, updating, and maintaining benefit plans, providercontracts, fee schedules, and various system tables through the user interface.
- Works with fluctuating volumes of work and is able to prioritizework to meet deadlines and needs of the department.
- Reviews documentation regarding updates/changes to memberenrolment, provider contract, provider demographic information,claim processing guidelines, and/or, system configuration requirements.
- Evaluates the accuracy of these updates/changes asapplied to the appropriate modules within the core processing system(O2).
- Conducts audits on samples of processed transactions impacted bythese updates/changes.
- Determines that all outcomes are aligned tothe original documentation and allows appropriate processing.
- Clearly documents the audit results and makes recommendations asnecessary.
- Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 10 days oferror issuance.
- Helps to evaluate the adjudication of claims using standard principles and specific policies and regulations to identify incorrectcoding, abuse and fraudulent billing practices, waste, overpayments,and processing errors of claims.
- Prepares, tracks, and provides audit findings reports according to designated timelines
- Presents audit findings and makes recommendations to managementfor improvements based on audit results.
- Provides input from a system perspective, into the year-end process,new projects, system failures, file failures, and claims errors.
The escalation point for the business and IT.
- Investigates escalation regarding Electronic Remittance Advice (ERA) to providers
- Provides the initial system set up for new schemes and options
- Updates and creates tariffs, limits, and rules on the online system -liaise with the fund and provider negotiations.
- Updates and creates limits and templates, events, and rules on theonline system (includes updates to modifiers, unit, and rate table and liaises with Fund, Corporate Governance, and auditors.
- Conducts claims testing to avoid financial loss to the business.
- Actions exceptions on Kr1s reports ensure that the scheme/s areprotected against possible losses by each change made on the live system.
- Generates, Analyses and communicates claims impact to thebusiness, to ensure the most feasible decision is taken.
- Liaises with the business in terms of system impact, claims impact,and feasibility of business requests.
- Participates in scheme audit process with a zero audit finding the result.
- Documenting of Masterfile's and other business-related processes.
- Process improvements to masterfiles processes and other business-related processes.
- Initiates continuous improvement/ enhancements and Innovativechange initiatives in the working environment (including and notlimited to the system
- Handles escalations competently and provides ongoing feedback until the conclusion of escalation
- Create test packs for new development items and initiate testing andsign-off
- Monitor all interfacing and keep business informed where required
- Liaise with third parties when required
- Updating statement messages for supplier