Manager ( Pre-Auth and Claims Department)
2024-03-22 - 2024-08-28
Permanent
BEN000143
Admin, Office, Support & Call Centre
Gauteng , JHB - Eastern Suburbs
A Medical Insurance company based in Benoni is looking for a Manager to Manage the Pre-Auth and Claims department. The Manager will manage the accurate and timely processing of claims within established legal and company compliance guidelines. Manage the pre-authorisation department and facilitate the process of pre-authorisation as per requests from members for procedures and admissions.
Key Performance Areas Claims:Clinical Assessment of ClaimsAssess, process, and reconcile all claims received within defined SLAPaid out claims within defined SLA Pre-Auth:Manage pre-authorisation casesResolve escalated customer queries and complaintsDevelop and motivate staffPerform general administration dutiesFinancials Key Tasks CLAIMSClinical Assessment of Claims Assess the clinical appropriateness and necessity of claims based on clinical guidelines and protocols within policy limits Assess, process and reconcile all claims received within defined SLA Implement Cost managementReview trends and variancesMake necessary changes to improve performanceOversee that the systems are used effectively, to improve accuracy and minimise errorsHandle complex complaints and difficult customersFind, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planningTrack performance, based on business requirementsUp skill the team to resolve complaints quickly and efficientlyApply sound financial principles and processes to the businessManage profitability, compliance and continued growthTake responsibility for actions, projects, department and peopleTake initiative and work under own directionInitiate and generate activity and introduce changes into work processesMake quick, clear decisions which may include tough choices and considered riskUse appropriate templates and channels to report progress on a weekly and monthly basis.Adhere to deadlinesMaintain high accuracy and qualityCreate and execute a claims strategyManage client relationships and expectations as well as build collaborative and sustainable client relationshipsOversee the delivery of excellent claims service to internal and external clientsEstablish clients' needs and provide appropriate solutionsPut best practice processes in place and implement compliance thereofNegotiate and authorise large and complex claims in line with the mandates providedOversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staffMentor and coach team membersDelegate appropriate mandates to staffManage subordinates dailyResolve all IR and staff welfare issuesTrain and mentor, all staffOversee career development of staff Pay out claims within defined SLA Maintain good co-operation with internal and external stakeholders and provide necessary information and reports as per requirementsCoordinate, distribute and follow up on workload PRE-AUTH Manage pre-authorisation cases Advise on all rules and related information for campaigns and interventions to the team.Identify opportunities to improve and expand product and service offerings.Manage areas of critical compliance.Maintain service, quality, and desired outputs by enforcement of compliance to tactical policies, procedures and standards.Participate in the creation of new standards, control systems and procedures to maintain service delivery. Resolve escalated customer queries and complaints. Manage the risk that no misrepresentation of the product is allowed.Provide feedback to customers on matters resolved. Develop and motivate staff. Implement Cost management.Review trends and variances.Make necessary changes to improve performance.Oversee that the systems are used effectively, to improve accuracy and minimise errors.Handle complex complaints and difficult customers.Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning.Track performance, based on business requirements.Up skill the team to resolve complaints quickly and efficientlyApply sound financial principles and processes to the businessManage profitability, compliance and continued growthTake responsibility for actions, projects, department and peopleTake initiative and work under own directionInitiate and generate activity and introduce changes into work processesMake quick, clear decisions which may include tough choices and considered riskUse appropriate templates and channels to report progress on a weekly and monthly basisAdhere to deadlinesMaintain high accuracy and qualityOversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staffMentor and coach team membersDelegate appropriate mandates to staffManage subordinates dailyResolve all IR and staff welfare issuesTrain and mentor, all staffOversee career development of staff Perform general administration duties. Develop roster in line with operational plans and or schedulesGenerate reports on performance of the departmentPrepare and submit periodic reportsFinancials Load payment FilesProcess upfront payments to providers Essential Qualifications MatricBusiness Degree (e.g. B. Com, B.Sc. etc)FAIS Compliant (RE1 and RE5)Clinical QualificationSANC Registration Desirable Qualifications Accounting or Finance qualificationPre-authorisation and case management or relevant managed healthcare experienceMicrosoft Excel Intermediate or Advanced Certificate Essential Experience 3 years management experience within the financial services environment5 years' experience in the insurance industry or similar environment e.g. HealthcareExperience in the implementation of business change and optimisation projectsInsurance and/or medical aid experience Desirable Experience 2 years insurance industry experience Knowledge and Skills Knowledge of claims processing, approvalKnowledge of business policies, processes and procedures, legal complianceExpert technical knowledge involving coverage and contract interpretationLiability issues analysis experienceClaim litigation management skillsExperience in mediation/arbitration and dispute resolution managementNumerical skillsNegotiation and persuasion skillsNetworking skillsBusiness AcumenCustomer CentricRelationship building skillsExcellent organisational skillsExcellent written and communication skillsTime management skillsExcellent interpersonal skillsClient relationship-building skillsDirecting and Controlling skillsStaffing skills Attributes High degree of commitmentMotivatedDeadline orientated.Honest, Hardworking and Humble
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