Reference Number MMH240910-3
Job Title Specialised Care Query Resolution
Position Type Permanent
Role Family Client Services
Cluster Health Solutions
Remote Opportunity None of the time
Location - Country South Africa
Location - Province KwaZulu-Natal
Location - Town / City Durban, Cornubia
Introduction
Momentum Health Solutions, 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 adefined set of Health capabilities.
Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.
Role Purpose
To ensure that the Health Risk Management area enforces the principles of customer centricity and that the benefit design intent is carried through the patient advocacy process and that the member experience is seamless and of a high quality.
Requirements
- Matric
- Post Basic Pharmacy Assistant would be an advantage
- 5 years industry knowledge, especially in Oncology, renal dialysis and transplant programmes
- Experience in a clinical claims setting
- Knowledge of billing procedures from specialists and hospitals in specific
- Strong knowledge of managed care
- Solid understanding of the industry rules and regulations
- Solid understanding of clinical policies and its application in practise
- Good understanding of the Oracle system and internal processes within Momentum Health
- Solid understanding of the Momentum Health benefit
- Detailed knowledge of tariffs, prices, industry regulations, governing tariffs and scheme mandates in respect to paying forthe relevant tariffs
- Detailed working knowledge of all billing guidelines eg SAMA, NHRPL as well as individual hospital group billing guidelines
- Very good knowledge of the claims system, the claims logic and its effect on claims payment
- Root cause resolution of claims within specialised health offering
- Ensure effective claims management service delivery and support
- Provide first time resolution onqueries
- Develop effective relationshipswith stakeholders at all levels ofthe organisation, including 3rdparties and service providers.
- Through analysis, be able toassist problematic areas to reviewand redefine processes that willincrease efficiencies therebyincreasing the turnaround time onthe claim payment.
- Be able to resolve client issues with a reasonable amount of time and to the clients satisfaction
- Call client/provider back oncequery resolved
- Feedback appropriately andaccurately
- Ensure rigorous testing isconducted and test cases areapplied
- Liaising with the business ontrends that need to be collectivelyaddressed
- Identify areas where training isrequired to improve service leveland create processes that willaddress the shortcomings.
- Excellent Communication Skills(verbal and written)
- Good time management skills
- Planning and organizing
- Able to take initiative and be pro-active
- Creative problem solving
- People skills
- Stress tolerance
- Accurate and precise
- Solution driven
- Self starter
- Good interpersonal skills
- Excellent problem solving skills
- Ability to work under pressure
- Team player but able to function alone
- Able to share knowledge and support people
- Trouble shooting
