Job Description

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

This role offers exciting and challenging opportunities for a dynamic, performance-oriented, knowledgeable, and experienced individual. The candidate must deliver quality outputs in a fast-paced, high-volume client-oriented environment, excelling both independently and as part of a team. This position is essential for maintaining and improving the quality standards across the organisation, ensuring exceptional client service and operational efficiency.

Requirements

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Qualifications

Valid Matric Certificate
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Knowledge

Knowledge of Claims operating systems
Multi discipline claims knowledge
Ability to interpret and apply scheme rules correctly
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
Good knowledge of tariff codes, rules(Scheme and Industry), modifiers and their application
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
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Experience

3-5 years Claims assessing experience, preferably in a Medical Aid industry
Computer literacy (Email, Word and Excel)

Duties & Responsibilities

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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
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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
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PEOPLE

Build strong relationships by providing specialist know-how and leadership to others, expressing positive expectations
Continuously develop own expertise in industry and subject matter, applying it in specialisation
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
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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 investigation and resolution

Competencies

Excellent communication, listening and interpersonal skills
Ability to liaise professionally and courteously at all levels
Ability to exercise discretion
Pro-activeness and drive
Good decision-making skills
Assertiveness
Ability to work independently
Ability to work under pressure
Ability to remain and act neutral / impartial
Ability to communicate recommendations in a constructive manner
Sound knowledge of scheme rules and benefits
Be able to interpret payment instructions from relevant SPN's
* Be able to read claims raw data and access real-time claims