Job Description

Closing Date 2025/12/29
Reference Number MMH251128-17
Job Title Talent Pool: Query Resolution Team Leader
Position Type Permanent
Cluster Momentum Health
Remote Opportunity Some of the time
Location - Country South Africa
Location - Province Gauteng
Location - Town / City Sandton
Introduction
Through our client-facing brands Momentum Group, 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.
Role Purpose
Accountable for the day to day operations relative to the overall management of escalated and resolution of queries regarding claim related issues. Ensures that claims are paid as per the schemes rules and policies. Maintaining of service level agreements. Responsible for recommending strategic initiatives to enhance claims and auditing processes and procedures. Ensure operational efficiency and management of resources.
Requirements

• Completed Degree or studying towards a degree would be an advantage
• At least 10 years of experience in the medical aid environment
• Has held a management position dealing with staff for at least 5 years
• 5 years with in the claims and claims query processing area
• Excellent understanding and proficiency in the medical aid industry
• Additional clinical knowledge and or exposure to managed health care principal would be an advantage
• Sound understanding of medical aid tariffs, modifiers and there application.
• Excellent knowledge and understanding related to claims processes
• Excellent knowledge and understanding of tariffs, ICD10 and CPT codes
• Good accounting knowledge
• Oracle system preferred
• Excellent excel skills

Duties & Responsibilities
Internal Process

• Enhancements to processes and systems
• Creates and updates process documents related to process and audit processes and the sharing of these documents
• Minutes of meetings/projects
• Investigation of high level escalations -providing feedback to management
• Assisting the provider network department in regard to providers escalation that may require recon
• Stale claim analysis and report feedback
• Managing the pathology credit process.
• Liaising with the finance department in regard certain debt processes
• Correct application of policies and regulations
• Payment of valid claims
• Monitor service level agreements and reports
• Monthly Stats reports and providing feedback in regard to interpretation of the variances
• Manage weekly discipline reports
• Complete performance reviews
• Ensure accuracy of claims payment

Enable client centricity within area of responsibility
(Client Services)

• Provide authoritative, expertise and advice to clients and stakeholders
• Build and maintain relationships with clients and internal and external stakeholders
• Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments
• Define service practices which builds rewarding relationships, encourages innovation and allows others to provide exceptional client service.
• Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed
• Make recommendations to improve client service and fair treatment of clients within area of responsibility

Effectively lead team
(People)

• Create a positive work climate and culture to energise employees, give meaning to work, minimise work disruption and maximise employee productivity.
• Demonstrate exemplary leadership behaviour, through personal involvement, commitment and dedication in support of organisational values.
• Select and recruit suitably qualified talent in line with Employment Equity principles and MMI values
• Drive a culture that guides and directs best practice, fostering an environment of continuous learning, improvement and cohesiveness.
• Enable a learning and growth culture whereby information regarding successes, issues, trends and ideas are actively shared between team members.
• Execute effective workforce planning practices to ensure that staffing requirements are accurately forecasted
• Identify employee growth and development needs and schedule interventions to enable ongoing development, training and personal growth.
• Effectively manage performance within the team in order to ensure business objectives are achieved

Manage budget and implement sound financial controls
(Finance)

• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
• Identify solutions to enhance cost effectiveness and increase operational efficiency.
• Implement and provide input into governance processes, systems and legislation within area of specialisation.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes

Competencies

• Business Acumen - Understands how the business operates, what the key issues and risks are that drives business success; and how they impact on the commercial viability of potential ventures and the profitability of the Group.
• Client Commitment - Anticipates, meets and exceeds client's needs by creating long lasting relationships that support the client value proposition, supports their financial wellness and ensures client centricity.
• Drive for Results - Drive a sense of urgency, focus, accountability, agility and execution to deliver business results.
• Leads Change and Innovation - Actively leads change, does what is right for the business and drives continuous improvement through innovation.
• Motivating and Inspiring Team - Creates and maintains an open, positive working environment by generating commitment, building trust, a shared sense of purpose, empowerment in others and encouraging them to contribute to the best of their ability.
• Collaboration - Prioritises the business interests of Momentum Metropolitan and invests in the success of the group by aligning effort across divisions.
• Impact and Influence - Persuades, convinces, influences and inspires others, both within Momentum Health and externally to win support, loyalty and gain commitment to the purpose of Momenum Health.
• Self-Awareness and Insight - Manages self and relationships with others effectively and provides perspective in difficult situations.
• Diversity and Inclusiveness - Is sensitive to individual and cultural similarities and differences and demonstrates humility and an openness to engage people from diverse backgrounds and cultures to the mutual benefit of all parties concerned.
• Growing Talent - Takes responsibility for own development; and actively mentors, coaches and develops talent in others. Builds leadership bench strength for MMI by providing opportunities and experiences to develop skills, competencies and business knowledge.

Policy
We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.

Skills Required