Technical Support Specialist at Momentum Metropolitan Holdings Limited

Requirements

• Matric / Grade 12
• A bachelor degree or equivalent qualification in a relevant field such as Computer Science, Information Technology, Engineering, or a related discipline.
• 3 - 5 years relevant experience as a Business Operations Specialist/ Technical Specialist or equivalent area/role
• Working experience within a quality assurance environment.
• In-depth understanding of claims assessing processes, including evaluating eligibility, appropriateness, and reimbursement based on policy guidelines, medical codes, and billing rules.
• Proficient knowledge of various medical scheme benefit designs, coverage levels, limitations, and exclusions for accurate claims assessment and reimbursement determination.
• Comprehension and interpretation of billing rules governing medical claims processing, along with familiarity with relevant systems and technologies used for claims adjudication.
• Knowledge of the legal framework and regulations, including the Medical Scheme's Act and related guidelines, ensuring compliance and adherence to regulatory requirements.
• Extensive knowledge of medical industry terminology, including medical conditions, procedures, treatments, and diagnostic coding (e.g., ICD-10), facilitating accurate claims assessment, effective communication with healthcare professionals, and appropriate code assignment.
• Specific understanding of operational processes within the healthcare industry, including case management, call center operations, and membership management, to effectively support operational requirements.
• Thorough understanding/proficiency of the operational system utilised within the quality assurance space (e.g., Vitel, Reflections, Cubes etc.).
• Proficiency in working with O2 or similar health insurance platforms to process claims, manage member information, and generate reports for analysis and decision-making.
• Strong proficiency in using Microsoft Word and Excel for documentation, data analysis, and report generation, ensuring accuracy and clear presentation.
• Solid understanding of the medical aid industry's processes, regulations, and dynamics.

Duties & Responsibilities

PROCESS

• Provide high-quality business operation and technical support to maintain organisational processes, ensuring smooth operations.
• Apply innovative/creative thinking by identifying gaps, proposing solutions/enhancements, and presenting them to maximise process efficiency.
• Establish and nurture key relationships with internal and external stakeholders to facilitate collaboration and effective communication.
• Investigate and resolve any business escalations received, ensuring accurate and timely resolution to maintain operational effectiveness.
• Participate in external and internal audits, contributing to compliance and process improvement efforts.
• Assist in the drafting and maintenance of Quality Assurance Frameworks, ensuring they are up-to-date and aligned with requirements.
• Build data models based on stakeholder requirements to support data-driven decision-making.• Collaborate with stakeholders to define reporting requirements and timeframes, delivering accurate reports as per agreed-upon standards.
•  Compile and obtain appropriate sign-off for stakeholder reports, operational reports, and administrative reports to support decision-making.
• Provide technical assistance to QA and Governance staff, offering expertise and support as needed.
• Maintain an internal data and reporting repository for the Governance and Quality Assurance department, ensuring accessibility and data integrity.

CLIENT

• Build and maintain relationships with clients and internal/external stakeholders, fostering trust and effective collaboration.
• Meet service level agreements with clients and stakeholders, managing expectations and delivering quality service.
• Make recommendations to improve client service and ensure fair treatment of clients within the area of responsibility.
• Contribute to a positive culture that prioritises relationships, feedback, and exceptional client service.
• Monitor turnaround times and quality standards, resolving issues promptly to enhance client service delivery.
• Drive client service delivery goals, aligning with predefined standards and providing appropriate advice and after-sales service.
• Manage client query processes, tracking and resolving queries accurately, and utilising them as opportunities for improvement.

PEOPLE

• Build strong relationships by providing specialist knowledge and leadership, fostering positive expectations.
• Continuously develop expertise in industry and subject matter, applying it effectively in the area of specialisation.
• Positively influence and manage change, offering specialist support when needed.
• Foster a culture of continuous innovation by developing, sharing, and implementing new ideas with colleagues and staff.
• Contribute to a work-centric thinking culture that emphasises productivity, service delivery, and quality management.
• Take ownership of driving career development, proactively seeking growth opportunities.