Manager ( Pre-Auth and Claims Department) - Johannesburg
National Risk Managers Ltd
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 Claims Assess, process, and reconcile all claims received within defined SLA Paid out claims within defined SLA Pre-Auth: Manage pre-authorisation cases Resolve escalated customer queries and complaints Develop and motivate staff Perform general administration duties Financials Key Tasks CLAIMS Clinical 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 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 efficiently Apply sound financial principles and processes to the business Manage profitability, compliance and continued growth Take responsibility for actions, projects, department and people Take initiative and work under own direction Initiate and generate activity and introduce changes into work processes Make quick, clear decisions which may include tough choices and considered risk Use appropriate templates and channels to report progress on a weekly and monthly basis. Adhere to deadlines Maintain high accuracy and quality Create and execute a claims strategy Manage client relationships and expectations as well as build collaborative and sustainable client relationships Oversee the delivery of excellent claims service to internal and external clients Establish clients’ needs and provide appropriate solutions Put best practice processes in place and implement compliance thereof Negotiate and authorise large and complex claims in line with the mandates provided Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff Mentor and coach team members Delegate appropriate mandates to staff Manage subordinates daily Resolve all IR and staff welfare issues Train and mentor, all staff Oversee 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 requirements Coordinate, 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 efficiently Apply sound financial principles and processes to the business Manage profitability, compliance and continued growth Take responsibility for actions, projects, department and people Take initiative and work under own direction Initiate and generate activity and introduce changes into work processes Make quick, clear decisions which may include tough choices and considered risk Use appropriate templates and channels to report progress on a weekly and monthly basis Adhere to deadlines Maintain high accuracy and quality Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff Mentor and coach team members Delegate appropriate mandates to staff Manage subordinates daily Resolve all IR and staff welfare issues Train and mentor, all staff Oversee career development of staff Perform general administration duties. Develop roster in line with operational plans and or schedules Generate reports on performance of the department Prepare and submit periodic reports Financials Load payment Files Process upfront payments to providers Essential Qualifications Matric Business Degree (e.g. B. Com, B.Sc. etc) FAIS Compliant (RE1 and RE5) Clinical Qualification SANC Registration Desirable Qualifications Accounting or Finance qualification Pre-authorisation and case management or relevant managed healthcare experience Microsoft Excel Intermediate or Advanced Certificate Essential Experience 3 years management experience within the financial services environment 5 years’ experience in the insurance industry or similar environment e.g. Healthcare Experience in the implementation of business change and optimisation projects Insurance and/or medical aid experience Desirable Experience 2 years insurance industry experience Knowledge and Skills Knowledge of claims processing, approval Knowledge of business policies, processes and procedures, legal compliance Expert technical knowledge involving coverage and contract interpretation Liability issues analysis experience Claim litigation management skills Experience in mediation/arbitration and dispute resolution management Numerical skills Negotiation and persuasion skills Networking skills Business Acumen Customer Centric Relationship building skills Excellent organisational skills Excellent written and communication skills Time management skills Excellent interpersonal skills Client relationship-building skills Directing and Controlling skills Staffing skills Attributes High degree of commitment Motivated Deadline orientated. Honest, Hardworking and Humble For more information please contact: Koana Lamola
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