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    Manager ( Pre-Auth and Claims Department) - Johannesburg, South Africa - National Risk Managers

    National Risk Managers
    National Risk Managers Johannesburg, South Africa

    3 days ago

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    Description
    A Medical Insurance company based in Benoni is looking for a Manager to Manage the Pre-Auth and Claims department. The Manager will manage the accurate and timely processing of claims within established legal and company compliance guidelines. Manage the pre-authorisation department and facilitate the process of pre-authorisation as per requests from members for procedures and admissions.

    Key Performance Areas
    • Claims:
    • Clinical Assessment of Claims
    • Assess, process, and reconcile all claims received within defined SLA
    • Paid out claims within defined SLA
    • Pre-Auth:
    • Manage pre-authorisation cases
    • Resolve escalated customer queries and complaints
    • Develop and motivate staff
    • Perform general administration duties
    • Financials

    Key Tasks
    • CLAIMS
    Clinical Assessment of Claims
    • Assess the clinical appropriateness and necessity of claims based on clinical guidelines and protocols within policy limits

    Assess, process and reconcile all claims received within defined SLA
    • Implement Cost management
    • Review trends and variances
    • Make necessary changes to improve performance
    • Oversee that the systems are used effectively, to improve accuracy and minimise errors
    • Handle complex complaints and difficult customers
    • Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning
    • Track performance, based on business requirements
    • Up skill the team to resolve complaints quickly and efficiently
    • Apply sound financial principles and processes to the business
    • Manage profitability, compliance and continued growth
    • Take responsibility for actions, projects, department and people
    • Take initiative and work under own direction
    • Initiate and generate activity and introduce changes into work processes
    • Make quick, clear decisions which may include tough choices and considered risk
    • Use appropriate templates and channels to report progress on a weekly and monthly basis.
    • Adhere to deadlines
    • Maintain high accuracy and quality
    • Create and execute a claims strategy
    • Manage client relationships and expectations as well as build collaborative and sustainable client relationships
    • Oversee the delivery of excellent claims service to internal and external clients
    • Establish clients' needs and provide appropriate solutions
    • Put best practice processes in place and implement compliance thereof
    • Negotiate and authorise large and complex claims in line with the mandates provided
    • Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff
    • Mentor and coach team members
    • Delegate appropriate mandates to staff
    • Manage subordinates daily
    • Resolve all IR and staff welfare issues
    • Train and mentor, all staff
    • Oversee career development of staff

    Pay out claims within defined SLA
    • Maintain good co-operation with internal and external stakeholders and provide necessary information and reports as per requirements
    • Coordinate, distribute and follow up on workload

    PRE-AUTH
    Manage pre-authorisation cases
    • Advise on all rules and related information for campaigns and interventions to the team.
    • Identify opportunities to improve and expand product and service offerings.
    • Manage areas of critical compliance.
    • Maintain service, quality, and desired outputs by enforcement of compliance to tactical policies, procedures and standards.
    • Participate in the creation of new standards, control systems and procedures to maintain service delivery.

    Resolve escalated customer queries and complaints.
    • Manage the risk that no misrepresentation of the product is allowed.
    • Provide feedback to customers on matters resolved.

    Develop and motivate staff.
    • Implement Cost management.
    • Review trends and variances.
    • Make necessary changes to improve performance.
    • Oversee that the systems are used effectively, to improve accuracy and minimise errors.
    • Handle complex complaints and difficult customers.
    • Find, recruit and retain top talent maintain efficiencies in terms of structure, workload and resource planning.
    • Track performance, based on business requirements.
    • Up skill the team to resolve complaints quickly and efficiently
    • Apply sound financial principles and processes to the business
    • Manage profitability, compliance and continued growth
    • Take responsibility for actions, projects, department and people
    • Take initiative and work under own direction
    • Initiate and generate activity and introduce changes into work processes
    • Make quick, clear decisions which may include tough choices and considered risk
    • Use appropriate templates and channels to report progress on a weekly and monthly basis
    • Adhere to deadlines
    • Maintain high accuracy and quality
    • Oversee and manage relationships including setting of performance goals and provide ongoing feedback on performance to staff
    • Mentor and coach team members
    • Delegate appropriate mandates to staff
    • Manage subordinates daily
    • Resolve all IR and staff welfare issues
    • Train and mentor, all staff
    • Oversee career development of staff

    Perform general administration duties.
    • Develop roster in line with operational plans and or schedules
    • Generate reports on performance of the department
    • Prepare and submit periodic reports
    Financials
    • Load payment Files
    • Process upfront payments to providers


    Essential Qualifications
    • Matric
    • Business Degree (e.g. B. Com, B.Sc. etc)
    • FAIS Compliant (RE1 and RE5)
    • Clinical Qualification
    • SANC Registration

    Desirable Qualifications
    • Accounting or Finance qualification
      • Pre-authorisation and case management or relevant managed healthcare experience
      • Microsoft Excel Intermediate or Advanced Certificate

    Essential Experience
    • 3 years management experience within the financial services environment
    • 5 years' experience in the insurance industry or similar environment e.g. Healthcare
    • Experience in the implementation of business change and optimisation projects
    • Insurance and/or medical aid experience

    Desirable Experience
    • 2 years insurance industry experience

    Knowledge and Skills
    • Knowledge of claims processing, approval
    • Knowledge of business policies, processes and procedures, legal compliance
    • Expert technical knowledge involving coverage and contract interpretation
    • Liability issues analysis experience
    • Claim litigation management skills
    • Experience in mediation/arbitration and dispute resolution management
    • Numerical skills
    • Negotiation and persuasion skills
    • Networking skills
    • Business Acumen
    • Customer Centric
    • Relationship building skills
    • Excellent organisational skills
    • Excellent written and communication skills
    • Time management skills
    • Excellent interpersonal skills
    • Client relationship-building skills
    • Directing and Controlling skills
    • Staffing skills

    Attributes
    • High degree of commitment
    • Motivated
    • Deadline orientated.
    • Honest, Hardworking and Humble
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