Manager ( Pre-Auth and Claims Department)

1 month ago

Johannesburg, South Africa National Risk Managers Full time
A Medical Insurance company based in Benoni is looking for a Manager to Manage the Pre-Auth and Claims department. The Manager will manage the accurate and timely processing of claims within established legal and company compliance guidelines. Manage the pre-authorisation department and facilitate the process of pre-authorisation as per requests from members for procedures and admissions.

Key Performance Areas
  • Claims:
  • Clinical Assessment of Claims
  • Assess, process, and reconcile all claims received within defined SLA
  • Paid out claims within defined SLA
 
  • Pre-Auth:
  • Manage pre-authorisation cases
  • Resolve escalated customer queries and complaints
  • Develop and motivate staff
  • Perform general administration duties
  • Financials
 
Key Tasks
 
  • CLAIMS
Clinical Assessment of Claims
  • Assess the clinical appropriateness and necessity of claims based on clinical guidelines and protocols within policy limits
 
Assess, process and reconcile all claims received within defined SLA
  • Implement Cost management
  • Review trends and variances
  • Make necessary changes to improve performance
  • Oversee that the systems are used effectively, to improve accuracy and minimise errors
  • Handle complex complaints and difficult customers
  • Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning
  • Track performance, based on business requirements
  • Up skill the team to resolve complaints quickly and efficiently
  • Apply sound financial principles and processes to the business
  • Manage profitability, compliance and continued growth
  • Take responsibility for actions, projects, department and people
  • Take initiative and work under own direction
  • Initiate and generate activity and introduce changes into work processes
  • Make quick, clear decisions which may include tough choices and considered risk
  • Use appropriate templates and channels to report progress on a weekly and monthly basis.
  • Adhere to deadlines
  • Maintain high accuracy and quality
  • Create and execute a claims strategy
  • Manage client relationships and expectations as well as build collaborative and sustainable client relationships
  • Oversee the delivery of excellent claims service to internal and external clients
  • Establish clients’ needs and provide appropriate solutions
  • Put best practice processes in place and implement compliance thereof
  • Negotiate and authorise large and complex claims in line with the mandates provided
  • Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff
  • Mentor and coach team members
  • Delegate appropriate mandates to staff
  • Manage subordinates daily
  • Resolve all IR and staff welfare issues
  • Train and mentor, all staff
  • Oversee career development of staff
 
Pay out claims within defined SLA
  • Maintain good co-operation with internal and external stakeholders and provide necessary information and reports as per requirements
  • Coordinate, distribute and follow up on workload
 
PRE-AUTH
Manage pre-authorisation cases
  • Advise on all rules and related information for campaigns and interventions to the team.
  • Identify opportunities to improve and expand product and service offerings.
  • Manage areas of critical compliance.
  • Maintain service, quality, and desired outputs by enforcement of compliance to tactical policies, procedures and standards.
  • Participate in the creation of new standards, control systems and procedures to maintain service delivery.
 
Resolve escalated customer queries and complaints.
  • Manage the risk that no misrepresentation of the product is allowed.
  • Provide feedback to customers on matters resolved.
 
Develop and motivate staff.
  • Implement Cost management.
  • Review trends and variances.
  • Make necessary changes to improve performance.
  • Oversee that the systems are used effectively, to improve accuracy and minimise errors.
  • Handle complex complaints and difficult customers.
  • Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning.
  • Track performance, based on business requirements.
  • Up skill the team to resolve complaints quickly and efficiently
  • Apply sound financial principles and processes to the business
  • Manage profitability, compliance and continued growth
  • Take responsibility for actions, projects, department and people
  • Take initiative and work under own direction
  • Initiate and generate activity and introduce changes into work processes
  • Make quick, clear decisions which may include tough choices and considered risk
  • Use appropriate templates and channels to report progress on a weekly and monthly basis
  • Adhere to deadlines
  • Maintain high accuracy and quality
  • Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff
  • Mentor and coach team members
  • Delegate appropriate mandates to staff
  • Manage subordinates daily
  • Resolve all IR and staff welfare issues
  • Train and mentor, all staff
  • Oversee career development of staff
 
Perform general administration duties.
  • Develop roster in line with operational plans and or schedules
  • Generate reports on performance of the department
  • Prepare and submit periodic reports
Financials
  • Load payment Files
  • Process upfront payments to providers
 
 
Essential Qualifications
  • Matric
  • Business Degree (e.g. B. Com, B.Sc. etc)
  • FAIS Compliant (RE1 and RE5)
  • Clinical Qualification
  • SANC Registration
 
Desirable Qualifications
  • Accounting or Finance qualification
    • Pre-authorisation and case management or relevant managed healthcare experience
    • Microsoft Excel Intermediate or Advanced Certificate
 
Essential Experience
  • 3 years management experience within the financial services environment
  • 5 years’ experience in the insurance industry or similar environment e.g. Healthcare
  • Experience in the implementation of business change and optimisation projects
  • Insurance and/or medical aid experience
 
Desirable Experience
  • 2 years insurance industry experience
 
Knowledge and Skills
  • Knowledge of claims processing, approval
  • Knowledge of business policies, processes and procedures, legal compliance
  • Expert technical knowledge involving coverage and contract interpretation
  • Liability issues analysis experience
  • Claim litigation management skills
  • Experience in mediation/arbitration and dispute resolution management
  • Numerical skills
  • Negotiation and persuasion skills
  • Networking skills
  • Business Acumen
  • Customer Centric
  • Relationship building skills
  • Excellent organisational skills
  • Excellent written and communication skills
  • Time management skills
  • Excellent interpersonal skills
  • Client relationship-building skills
  • Directing and Controlling skills
  • Staffing skills
 
Attributes
  • High degree of commitment
  • Motivated
  • Deadline orientated.
  • Honest, Hardworking and Humble

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