Never pay for any CBT, test or assessment as part of any recruitment process. When in doubt, contact us
MMI Holdings Limited (MMI), a South African-based financial services group was established on 1 December 2010, through the merger of Metropolitan Holdings and Momentum Group. We are specialists in long and short-term insurance, asset management, savings, investments, healthcare administration, health risk management, employee benefits and rewards programmes.
Job description
Division: MMI Health - Bellville
Introduction
Metropolitan is one of the oldest financial services brands in South Africa. With a 116 year legacy of serving the communities in which it operates, Metropolitan represents true empowerment in serving Africa's people through affordable financial solutions that create financial growth and security. Metropolitan operates in South Africa, but the brand is also present in 12 African countries including, Namibia, Botswana, Kenya, Ghana, Nigeria, Lesotho, and Swaziland. Metropolitan provides financial wellness solutions that meet the needs of low income clients, including funeral insurance, health, savings, hospital cash-back cover, retirement solutions and life insurance.www.metropolitan.co.za
Role Purpose
- Claims Risk Management aims to balance access to high quality, affordable healthcare for all members, while ensuring sustainability of the scheme. The purpose of this role is :
- To develop, manage and co-ordinate projects and initiatives to manage Claim's risk
- Influence business strategy and manage costs of the scheme through various projects and risk mitigating strategies/interventions.
Requirements
Minimum Qualification Required:
- Matric/Grade 12
- A Bachelor's Degree is essential, preferably with a clinical background
- A post-graduate degree or MBA will be advantageous
Minimum Experience Required:
- 3 - 5 years at a Senior Management level
- 5 - 10 years Operational and Clinical Claims Management
- Basicunderstanding of clinical coding
- Managed health care experience/Clinical Risk Management or any administrative healthcare setting
- Strong analytic background
- Understanding of the Managed Care environment
- Understanding of the Healthcare Provider Landscape
- Comfortable to engage at Executive level
- A very strong Finance and Operational management background
- Must demonstrate expert-level knowledge and awareness of Stakeholder Relationship Management
- Strong Claims Management background
- The work you need to deliver
- Strategic Risk Management Strategy Formulation
- Develop a clear strategic risk management (SRM)strategy and framework for Metropolitan Health(MH)
- Drive initiatives to ensure sustainability of the Scheme
- Position MH as the trusted advisor in the area of SRM
- Manage Fraud, Waste and Abuse
- Establishment and management of a Fraud Steering Committee comprising senior management to ensure that the business adopts a more systematic, coordinated approach in interventions
- Develop models to identify and manage fraudster
- Management of recoveries
- Preventative measures for managing risk
- Stakeholder Relationship Management (Internal & External)
- Foster a collaborative relationship between Service Provider Network (SPN) members in order to promote the Scheme's strategic deliverables
- Providing effective communication on clinical risk issues to relevant scheme committees and engagements
- Claims Risk Forum Management
- Implement and monitor new products and projects
- Proactively engage with analysts in understanding risks to the scheme
- Chair the Claims Risk Forum and the Fraud Steering Committee
- Benefit Design
- Insights driven benefit design
- Proposal to the Scheme benefit design forum
- Clinical Risk Management
- Health economics evaluation models
- Development of Protocols and treatment plans
- Claims Policy Management
- Master file management
- New technology and Drugs payment framework
- Governance on claims adjudication systems
- Underwriting governance
- Professional/Billing Intelligence
- Consolidation of a number of risk management portfolios dealing with healthcare professionals, namely : Radiology , Pathology , Allied Providers and Medical Practitioners
- Tariff management – clinical , industry and best practice billing
- Coding – CPT and ICD 10
- Practice number management
- Healthcare Profiling
- Profiling tools and scorecard for providers
- Profiling tools and scorecard for facilities
- Reporting and communication to providers
- Drug & Surgical Management
- Medicine strategies – formularies including high cost drugs
- Surgical strategies – internal & external prosthesis
- Manufacture engagement models
- Support the Financial Sustainability of the Scheme
- Support the Financial Sustainability of the Scheme by reviewing:
- Solvency of the Scheme
- Claims Ratios
- Reserve Ratios
- Revenue for MH
- Support the BU's Contractual requirement in relation to the Attribution model
- Ensure that the BU meets its Service Level Agreements in the Fraud and Abuse Management System (FAMS)
- Competencies required
- Business Acumen
- Client/Stakeholder Commitment
- Drive for Results
- Leads Change and Innovation
- Motivating and Inspiring Team
- Strategic Thinking
- Collaboration
- Impact and Influence
- Self-Awareness and Insight
- Diversity and Inclusiveness
- Growing Talent
Should you be interested in applying for this position please click on apply, for any enquires please contact:
Gmail
Yahoomail