- To provide an effective and efficient service to clients by receiving, evaluating and responding to telephonic/electronic enquiries timeously.
- Grade 12/Matric.
- Relevant tertiary qualification would be an advantage, Customer Relationship Management, Business.
- Management, Project Management, and Operations Management.
- Claims School Training.
- 2 -3 years in the medical aid industry:
- 2 – 3 years Claims processing experience within the medical aid industry.
- 2 –3 years of query management experience.
- 2 – 3 years of client service experience.
- Good understanding of the MH systems would be an advantage.
- Good written and verbal communication as well as Excel knowledge and application.
- Understanding and knowledge of the interpretation and application of CMS, DoH, BHF, Private hospitals, etc.
Responsibilities And Work Outputs
- Interaction with the Clinical Advisors i.e. Medical Advisors, Radiologist, Pathology.
- Internal communication and relationship building.
- Building and nurturing the SPN partnership.
- Extensive interaction with Customer Experience
- Communicates and interacts with Bureaus and Service providers.
- Deliver meaningful and relevant feedback and communication.
- Extensive communication within the GEMS BU as well as external service providers and bureaus.
- Scrutinize all suspected inappropriate/ irregular claims appearing on the Metropolitan Expert Tool (QES /MES), (GP’s, Specialists, Allied Health and Radiologist) and ensuring appropriate processing.
- Applying in-depth knowledge and interpretation of both SAMA and RPL rules, tariffs and modifiers,
- Applying the Scheme specific Rules to inappropriate claims E.g. scheme exclusions on (QES / MES).
- Investigate and actioning adhoc written enquiries from the business units.
- Interact with the various medical advisors on an ongoing basis and to co-ordinate flow of queries.
- Address correspondence pertaining to investigations and follow-ups.
- Identify trends from QES/MES activities and referring Providers Profiles to forensics for investigation.
- Provide clinical interpretation and appropriateness of claims in accordance with Scheme Rules.
- Make recommendations to team leader/manager regarding new rules to be added to QES / MES rules engine.
- Identify new risk areas and make recommendations to team leaders/manager.
- Initiate correspondence pertaining to all Clinical Audit investigations both written and e-mail.
- Respond to written communication and investigating to queries relating to Clinical Audit Departmentfunctions.
- Liaise with Client Service, Claims and CMS regarding correspondence queries.
- Check doctors claim history.
- Determine what is settled and what must still be processed for payment.
- Do the necessary rejections using the correct rejection codes.
- Do necessary reversals where required.
- Routing of claims or documents to the relevant departments.
- Reprocessing of accounts from the Y- Pends.
- Loading of appliance filters once approved by MHRS and Y-Pend to the filter queue for reprocessing.
- Loading aPMB faxes filter on the filter screen once approved by MHRS and Y- Pend to the filter queue for reprocessing.
- Hospital claims reversal requests received from MHRS to be reversed with reversal code 9929.
- Review all medicines with nappi codes.
- Reversal and reprocessing and submit to MediKredit.
- Refereurgent special batches for urgent queries.
- Reprocessing of Ex- gratia claims that are received from the ex-gratia department and provide feedback once completed.
- Loading of rule and auth filters for Ex-gratia.
- Load filters related to Appliance Approvals, Ex Gratia, PMB and Exclusions.
- Provide ex-gratia with scheme rates when required.
- Scrutinize, review, reverse and reprocess claims received as complaints from Customer Experience and Fund.
- Provide written and/or telephonic responses to Customer Experience Team.
- Review tariff modifier combination billings and apply it when processing claims.
- Apply and understand Tariff codes, Tariff rules and Tariff pricing.
- Liaise with internal clients as well as external clients (Members and Providers).
- Identify errors by operators and e-mail the operator to fix error and cc both team leaders. Follow up within24hrs.
- Management including knowledge of ICD and CPT coding.
- Business Acumen.
- Client/ Stakeholder Commitment.
- Impact and Influence.
- Drive for Results.
- Works independently.
- Leads Change and Innovation.
- Diversity and Inclusiveness.
- Shortlisted candidates will be subjected to the following statutory checks:
- ITC Checks.
- Qualification Checks.
- Reference Checks.
- Psychometric assessments.
We reserve the right not to fill the vacancy. Should you not receive any response in respect of your application within 2 weeks, please consider your application unsuccessful.
Only on-line applications submitted via our careers page will be considered.
Internal Team Members must inform their manager of their application. Your manager must be aware of and support your application.
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