New Vacancies at PPS

Qualifications & Experience

• Matric
• Business related qualification (Forensics/Internal Audit/Commercial/IT).
• Medical Scheme Administration Experience, 1-2 years essential.
• Medical Aid Industry Billing and Coding practices
• Clinical and or Forensic background would be an advantage.
• Data Analytics exposure will be an advantage
• Ability to work cohesively in a team environment and balance multiple priorities.
• A team player who can work alone when required and without supervision.
• High level of attention to detail, resilience, enthusiasm, energy and drive.
• Positive, can-do attitude.
• Ethical and able to maintain confidentiality and manage boundaries.

Duties and Responsibilities    

KEY RESPONSIBILITIES INCLUDE:

• Investigating allegations of healthcare fraud against providers.
• Investigation of fraud cases received via Whistle-blowers and internally.
• Following up on leads regarding allegations of healthcare fraud.
• Using CAAT’s, identify claims that have been processed incorrectly.
• Conducting investigations into all aspects pertaining to healthcare fraud.
• Instituting measures to prevent fraud.
• Engaging perpetrator/s and taking necessary action where applicable.
• Analysing data to identify possible fraudulent trends i.e. coding, drugs analysis etc.
• Supply feedback to the Group Manager with regards to forensic audit findings.
• Perform internal audit as and when required.
• Liaise with scheme clients on the outcome of the investigation.

Additional tasks and responsibilities:

• Mend the RFMCF fraud line.
• Doing administrative tasks.
• Ad-hoc requests

KNOWLEDGE AND SKILLS

• Confident and professional manner.
• Articulate, both verbally and writing.
• Objective, logical and enquiring mind.
• Strong analytical and problem-solving skills.
• Good project management and team working ability
• Good time Management.
• Must be able to work independently and under pressure.

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Education: 

• Degree in Occupational Therapy or Physiotherapy 

Experience:

• 5+ years’ experience in the insurance industry.
• 4+ years’ experience in claims assessment including Income protection, Lump Sum.
• Disability and dread disease.
• Case Management experience is an advantage.

Knowledge and Skills:

• Fluent in English both written and verbal.
• Must have excellent telephone etiquette.
• Good computer knowledge - MS Outlook, Excel and Word are necessary.
• Good report writing and presentation skills.
• Must have a mature, disciplined and driven personality.
• Ability to work independently as well as being a good team-player with excellent interpersonal skills .
• Attention to detail.
• Deadline/target driven, with ability to work under pressure.
• Logical and analytical.
• Effective time management skills.

Competencies:

• Communication skills (written and verbal).
• Business writing skills.
• Planning and organizing.
• Attention to detail.
• Client centricity.
• Building and maintaining relationships.
• Resilience.

Duties and Responsibilities    

Process optimization and efficiencies:

• Assessment and management of long-term Sickness, Permanent Incapacity and Disability claims.
• Check the technical aspects of the claim – Inclusive of potential non-disclosure, and exclusions.
• Review all medical information on file, analyze and synopsize information at hand.
• Determine and record additional required information.
• Decide on referral to an independent specialist.
• Receive Independent Specialist reports and analyze and synopsize the report in context of the claim and PPS Provider Policy.
• Present the claims at Medical Officers Committee for assessment.
• Prepare detailed referral letters to independent specialists and detailed decision letters to members.
• Manage long-term claims by facilitating potential rehabilitation and return to work programs with appointed specialists.
• Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
• Conduct member visits or member meetings when required.
• Keeping accurate records of all claims assessed in accordance with departmental procedures.
• Deal with first line queries by members and brokers telephonically and via e-mail.
• Deal with Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
• Participation in projects to improve departmental service-owning your role in the project and completing tasks as required by providing input.

Risk and Compliance:

• Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards.
• Proficient in the assessment and management of claims.
• Must understand claims environment and general claims protocols and processes.
• Ensure adherence to audit requirements.
• Ensure adherence to regulatory and compliance requirements.

People and Culture:

• Checking and Authorization of claims in terms of published delegation of authority.
• Collaboration with relevant stakeholders: Research & Development, Legal, Operational Accounts, Non-disclosure and Internal Control.
• Contribute and assist to review processes and protocols where required to assist in PPS’ delivery of quality claims decisions.
• Forge strong working relationships with stakeholders.

Knowledge Champion  :

• Empower team members with transfer of knowledge, be the Operations Team SME.
• Ensure that own knowledge is kept abreast with industry & regulatory information and changes through various internal and external information sources.
• Provide technical information and support.

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Education:

• Matric.
• A 3-year tertiary qualification (NQF6 or above) with relevant business orientation (Advantageous).

Experience:

• 1 to 2 years of experience in an administration environment.
• Experience in the policy administration environment would be beneficial.
• Call Centre experience would be beneficial to assist with telephonic enquiries.

Knowledge and Skills:

• A good business acumen.
• Knowledge of Financial institutions (advantageous).
• Computer Literate (MS Office Package).
• Have excellent administration skills.
• Display attention to detail and analytical skills.
• Have strong organisational skills.

Competencies:

• Ability to communicate clearly and effectively both verbally and in writing.
• Demonstrate good telephone etiquette.
• Have good problem-solving abilities.
• Be solution driven and take accountability and responsibility of own work.
• Deadline and target driven particularly in a production environment.
• Be adaptable.
• Have an ability to work within a teamwork environment.
• Have stress tolerance and resilience.

Duties and Responsibilities    

Key Responsibilities

• Generate Counter offer Letters for Personal cover and Business Assurance, manual and system generated letters.
• Responding to customer inquiries (calls/emails) and resolving customer complaints professionally.
• Drafting of Underwriting correspondence letters, emails correspondence with reassurers and requirement letters.
• Resolve and respond to non-Disclosure queries.
• Review the HIV correspondence and to Liaise with the Medical Officer.
• Reviewing and uploading Trace and upload lab results.
• Taking ownership of service level standards and ensure they are reached consistently, accurately executing policies and procedures related to service delivery in Operations and other areas.
• Identifying and escalating priority issues.
• Data capturing of customer information, with a reduced element of error with accuracy and attention to detail in processing work.

Relationship Building & Communication   

• Collaborate effectively across business units to achieve business results.
• Build and maintain relationships with internal and external clients and stakeholders.

Maintain Product Expertise

• The Underwriting Administrator must be an expert in the products offered by PPS. This requires one to take the initiative to master every feature and benefit of each product. Identify process and procedure improvements and make recommendations to streamline and simplify processes.

 Assist Management and Support Team:

• Provide support to the broader Life Operations teams
• Assistance and finalisation of team projects
• Identify systems failures to escalate to the appropriate support team and implement required workarounds to prevent impact on member journey and productivity

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Education: 

• Medical qualification compulsory (Nursing, Occupational Therapy and Physiotherapy or related)

Experience:

• 5 years’ experience in the insurance industry.
• 3 years’ experience in claims assessment including Income protection, Lump Sum Disability and dread disease.

Knowledge and Skills:

• Fluent in English both written and verbal.
• Must have excellent telephone etiquette.
• Good computer knowledge - MS Outlook, Excel and Word are necessary.
• Good report writing and presentation skills.
• Must have a mature, disciplined and driven personality.
• Ability to work independently as well as being a good team-player with excellent interpersonal skills. 
• Attention to detail. 
• Deadline/target driven, with ability to work under pressure.
• Logical and analytical.
• Effective time management skills.

Competencies:

• Communication skills (written and verbal).
• Business writing skills.
• Planning and organizing.
• Attention to detail.
• Client centricity.
• Building and maintaining relationships.
• Resilience.

Duties and Responsibilities    

Process optimization and efficiencies:

• Assessment and management of short-term sickness, critical illness and death claims.
• Quality assurance and authorization of claims for Junior and Intermediate claims assessors.
• Facilitate complex claims discussions within the team, conduct training and coaching to the team and do claims presentations when required. 
• Assist team manager with daily queue management and reporting.
• Decide on referral to an independent specialist.
• Receive Independent Specialist reports and analyze and synopsize the report in context of the claim and PPS Provider Policy. 
• Keeping accurate records of all claims assessed in accordance with departmental procedures.
• Deal with deal with technical and complex claims queries and/or complaints providing an excellent service offering. 
• Deal with Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
• Participation in projects to improve departmental service-owning your role in the project and completing tasks as required by providing input.
• Facilitate and contribute to claims process improvements.

Risk and Compliance:

• Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards.
• Proficient in the assessment and quality assurance of claims.
• Must understand claims environment and general claims protocols and processes.
• Ensure adherence to audit requirements.
• Ensure adherence to regulatory and compliance requirements.

People and Culture:

• Checking and Authorization of claims in terms of published delegation of authority.
• Collaboration with relevant stakeholders: Research & Development, Legal, Operational Accounts, Non-disclosure and Internal Control.
• Contribute and assist to review processes and protocols where required to assist in PPS’ delivery of quality claims decisions.
• Forge strong working relationships with stakeholders.