Specialised Care Query Resolution - Durban, Cornubia at Momentum Metropolitan Holdings Limited

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
• 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 for the 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 claimspayment

Duties & Responsibilities    

• Root cause resolution of claims within specialised health offering
• Ensure effective claims management service delivery and support
• Provide first time resolution on queries
• Develop effective relationships with stakeholders at all levels of the organisation, including 3rd parties and service providers
• Through analysis, be able to assist problematic areas to review and redefine processes that will increase efficiencies thereby increasing the turnaround time on the claim payment
• Be able to resolve client issues with a reasonable amount of time and to the clients satisfaction
• Call client/provider back once query resolved
• Feedback appropriately and accurately
• Ensure rigorous testing is conducted and test cases are applied
• Liaising with the business on trends that need to be collectively addressed
• Identify areas where training is required to improve service level and create processes that will address the shortcomings.

Competencies    

• 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