Team Leader - Clinical Claims Adjudicator at Rand Mutual - RMA

THE JOB AT A GLANCE

As the Team Leader - Clinical Claims Adjudicator, you will be reporting to the Clinical Claims Manager, you will be responsible for leading and supervising the effective and efficient claims adjudication of COIDA and Non-COID i.e., ICD10 codes, Authorisation of treatment, TTD (Total Temporary Disability), claims estimates, Management of Claims MMI (Maximum Medical Improvement), PD (Percentage Disability) calculations and recommend Whole Person Impairment percentage, etc.

WHAT WILL YOU DO?

Team coaching and performance management

• Supervise the Clinical Claims Adjudication Team who is responsible for the Medical Management of claims aligned to treatment protocols and COIDA limits and generate Authorisation of treatment plans and devices
• Oversee the adjudication of valid disease claims in line with COIDA instructions
• Identify training needs for direct reports and maps development plans accordingly
• Coach and mentor direct reports
• Manage performance of staff (high and poor performance). Allocate, monitor and track achievement of performance targets for the team.

Reporting and project management

• Use appropriate templates and channels to report progress on a weekly and monthly basis
• Adhere to deadlines and ensure accuracy and quality of information
• Ensure that daily exceptions reports are actioned promptly
• Continuously review operations processes.

Organizing and workload management

• Ensure that work is promptly allocated to available staff in a balanced manner
• Ensure that all inter-departmental service levels are adhered to by staff
• Continuously monitor that daily targets of staff are met
• Conduct quality checks of the claims adjudicated by the team
• Manage the costs associated with the authorization and claims Estimates.

Communication and stakeholder management

• Provide Customer Service aligned to TCF
• Resolve queries which are escalated related to claims under their team’s control
• Engage relevant internal and external stakeholders to ensure understanding of COID claims processes
• Consistently identify and engage with relevant stakeholder in alignment with strategic goals.

WHAT YOU'LL BRING TO THE TABLE?

• NQF Level 7: Degree in Health Sciences (Nursing, Occupational Therapy and Physiotherapy)
• Experience and/or qualification in Occupational Health
• FSCA Regulatory Examination (RE5) Certificate
• FSCA Regulatory Examination (RE1) Certificate (advantageous)
• Registration with relevant Professional body (advantageous)
• Post-graduation certification/qualification in management (advantageous)
• 5 years' experience in medical aid claims environment or group life claims environment
• 2 to 3 years supervisory/team management experience
• Treatment Pre-authorization experience
• Occupational Health experience
• Whole person impairment Assessment experience
• COIDA experience (Insurance experience)
• Claims management experience.