Momentum Health Solutions (MHS), an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health and wellness 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 a defined set of health capabilities.
Role Purpose
To ensure hospital claims are audited timeously and accurately with the focus on reducing wastage and abuse, as well as to ensure that claims are processed according to authorisations.
Requirements
- A National Senior Certificate is essential
- It is essential to have a Nursing Diploma or Degree
- The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse
- Excellent understanding of the Medical Schemes Act, as well as PMB legislation
- Sound knowledge of ICD-10 and procedural coding
- MS Office proficiency
- Minimum of 2 years private hospital nursing experience
- Minimum of 1 years administrative exposure to the medical scheme industry
- Minimum of 1 years exposure to hospital claim processes, billings and tariffs
- Previous exposure to clinical auditing is highly advantageous
INTERNAL PROCESS
- Apply scheme rules, clinical policies and protocols to funding.
- Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
- Ensure accurate notes are made for all journals actioned on claims audited.
- Assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
- Ensure accurate completion of authorisations on claim finalisation.
- Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
- Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices & drug utilisation).
- Survey claims for correct application of tariff and refer discrepancies to the claim team.
- Review retrospective claim approvals and send journal instructions for additional payments to the claims team.
- Review hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.
- Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
- Escalate queries to the relevant team or stakeholder.
- Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
- Resolve claim queries accurately and timeously.
- Build and maintain relationships with internal and external stakeholders.
- Reduce claim rejections to ensure members are not held liable for unnecessary costs.
- Build strong relationships through expressing positive expectations.
- Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
- 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.
- Identify opportunities to enhance cost effectiveness and increase operational efficiency.
- Manage financial and other company resources under your control with due respect.
- Provide input into the risk identification processes and communicate recommendations in the appropriate forum.
- Teamwork
- Examining information
- Articulating information
- Upholding standards
- Accountability
- Attention to detail
- Time management
