Clinical Risk Consultant at Oneplan Underwriting Managers (Pty) Ltd

Key Responsibilities:

Claims Assessing and Claims Authorisation

• Authorization of Hospital (primarily), Day-to-day and/or all related claims as per policy terms and conditions and standard protocol.
• Working 12 hour shifts inclusive of weekends/public holidays/nights as per scheduling (Inherent requirement of the role).
• Inform customers/providers regarding invoices what will not be accepted or specific claim requirements via appropriate methods (email/ telephonically).
• Answer phones and respond to customer requests within the determined SLA.
• Explain products and update customer details in computer system.
• Provide customers with product and service information via appropriate methods (email/ telephonically).
• Follow and adhere to claims/company processes, procedures, and protocol.
• Recognize, document, and alert the supervisor of trends in customer calls/claims.
• Recommend process improvements.
• Focus on first call resolution as far as possible.
• Transfer customer calls to appropriate staff/department, where necessary.
• Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim.
• Daily reporting and updates: Ensure daily stats are updated and sent to supervisor/ manager at the end of each day. This includes submission of all relevant reports, paperwork and updates on all claims activity as directed, in a timeous manner.
• Assessing of claims according to standard operating procedure and company protocols.
• Improve client service experience, create engaged clients, and facilitate organic growth.
• Manages tasks allocated through omni-channel platforms.
• Handle complex and escalated client service issues.
• Build/maintain rapid channel of communication to client in case of service-related issues and events.
• Represent the “Voice of the Customer”.
• Create a culture of Customer/Client Centricity.
• Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Supervisor.
• Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
• Leverage team success to drive all initiatives and experiences with clients.
• Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
• Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client’s queries from end-to-end to ensure a world class client service experience.
• Support cross functional work areas targeted to resolve issues raised by clients.
• Proactively gather client feedback to optimize client experience.

Underwriting

• Underwriting according to protocol and to ensure effective risk management.
• Accurately Underwriting of new dependents, underwriting according to protocol and to ensure effective risk management.

Additional tasks

• Be available and willing to assist with any additional tasks and projects, as required by the department.
• Reviewing/capturing/assessing of specialized claims including but not limited to disability, dread, death and repatriation.
• Reviewing clinical guidelines/SOPs as required.

Claims Queries

• Identify, research, and resolve customer issues.
• Follow-up on customer enquiries not immediately resolved, within determined SLA’s.
• Educate clients on claims process as required.
• Assist and resolve claim queries and client complaints (telephonically/emails).

Quality, Consistency and Compliance

• Maintain QA call metrics as defined by the business.
• Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
• Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
• Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
• Maintain QA call metrics as defined by the business.
• Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
• Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
• Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
• Ensure quality assurance standards are met as per company guidelines.
• Ensure adherence to all relevant legislation and regulations as set out by the Company, Regulatory Board, and the Financial Services industry.

Work collaboratively

• Build a culture of respect and understanding across the organisation.
• Recognise outcomes which resulted from effective collaboration between teams.
• Build cooperation and overcome barriers to information sharing, communication, and collaboration across the organization.
• Facilitate opportunities to engage and collaborate with internal and external stakeholders to develop joint solutions.

Self-Management

• Follow through to ensure that personal quality and productivity standards are consistently and accurately maintained.
• Demonstrate consistent application of internal procedures.
• Plan and prioritise, demonstrating abilities to manage competing demands.
• Demonstrate abilities to anticipate and manage change.
• Demonstrate flexibility in balancing achievement of own objectives with abilities to understand and respond to organizational needs.

Requirements

Desired Skills & Experience:

Minimum Academic, Professional Qualifications & Experience required for this position.

• Grade 12 with English and a second language
• BSc Tertiary qualification or Nursing / Doctors Qualification will be favorably considered.
• RE5 (preferred)
• Successful candidate must have worked within a Medical Environment with a qualification for at least a 2 – 3 years works experience.
• Must have worked with Claims related to the health care and addressed queries within the role, managed customer service and claims experience on a day-to-day basis, with a minimum of 2 – 3 years.
• Relevant clinical qualification in related field advantageous (international nursing/medical provider qualifications will be considered whilst awaiting interim registration in SA)
• Meet FAIS fit and Proper requirements
• PC Literacy- word, excel, email and internet