Quality Assessor: Claims at Momentum Metropolitan Holdings Limited

INTRODUCTION

Momentum Health, an entity of Momentum Metropolitan Holdings Limited, delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities. This position can be based at either Parc du Cap, Cape Town or Sandton, Gauteng.

ROLE PURPOSE

Establishes, maintains and monitors a complete quality assurance claims system and ensures standards are met.

WHAT YOU'RE GOING TO DO

• Identifying training interventions to address individual needs.

• Quality checking random sample of claims and claims enquiries.

• Assist with staff development by identifying trend analysis and training needs through QA.

• Coaching of employees to support them in achieving the required standards

• Work with coaches and service managers and advise them of progress of staff.

• Maintaining the confidentiality of sensitive information.

• To facilitate and maintain open communication with other departments.

• Investigate client queries within the agreed service level and ensure that client receives timeous feedback.

• Provide regular reports on delivery of services against agreed service level agreements and in terms of overall customer targets.

• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.

• Develop and maintain productive and collaborative working relationships with peers and stakeholders.

• Positively influence and participate in change initiatives; continuously develop own expertise in terms of professional, industry and legislation knowledge.

• Contribute to continuous innovation through the development, sharing and implementation of new ideas.

• Take ownership for driving career development.

• Identify opportunities to enhance cost effectiveness and increase operational efficiency.

WHAT YOU'LL NEED:

• Matric

• 3-5 years Claims assessing experience in a Medical Aid industry.

• Thorough knowledge of the Claims operating systems.

• Multi discipline claims knowledge.

• The ability to interpret and apply scheme rules correctly.

• Knowledge of the NHRPL- National Health Reference Price List and SAMA tariffs.

• Good knowledge of PMB at industry level as well as in house PMB processes.

• Good knowledge of modifiers and their application.

• Computer literacy (especially Email, Word and Excel).

WHAT COMPETENCIES YOU'LL REQUIRE

• Excellent communication, listening and interpersonal skills.

• Ability to liaise professionally and courteously at all levels.

• Ability to exercise discretion.

• Pro-activeness and drive.

• Good decision making skills.

• Assertiveness.

• Ability to work independently.

• Ability to work under pressure.

• Ability to remain and act neutral / impartial.

• Ability to communicate recommendations in a constructive manner.

• Sound knowledge of scheme rules and benefits.

• Be able to interpret payment instructions from relevant SPN's.

• Be able to read claims raw data and access real-time claims.

• Be able to audit different kinds of claims.

ADDITIONAL INFORMATION

Shortlisted candidates will be subjected to the following statutory check:

• Psychometric Assessments

• References

• ITC

• Qualification

• Criminal

Please note that we reserve a right not to fill this vacancy. Should you not be contacted within two weeks, please consider your application unsuccessful.

DISCLAIMER

• Only on-line applications submitted via our careers page will be considered.

• Internal Team Members must inform their manager of their application. Your manager must be aware of and support your application.

• Please note: this vacancy is not open to recruitment agencies