JOB PURPOSE
Support the Manager in pre-approval, medical claims or customer service operations and ad hoc project work across the department to ensure adherence to company policies, standard operating procedures and regulatory authorities mandates. In all areas, maximise the use of automation to limit company expense and improve efficiency.
Ensure that Medical Benefits (MB) policy and procedures are upheld in all operational activity. Administrate projects, scheme updates and process revisions in line with MB objectives and management direction ensuring accurate documentation of process and policy change in line with audit parameters. Support management reporting with reports and dashboards.
JOB ACCOUNTABILITIES LINKED TO OBJECTIVE AREAS
Generic
- Support claims, pre-approvals and customer support teams across medical and administrative operations to ensure they are operated effectively within the MB team thereby ensuring consistency. Work with the Manager to identify and monitor quality and establish problem areas and implement corrective action.
- Maintain a consistent business process review approach making maximum use of automation to improve speed and quality of internal processes and the customer experience.
- Compile feedback from various sources thereby measuring external medical providers and healthcare benefits, documenting and investigating to seek recommendations for quality improvements.
Specific to Claims and pre-approvals processing
- Process pre-approvals and medical claims to determine cover in line with company terms and conditions. Make decisions with regards to payment, denials, investigations and reimbursement ensuring that company policies and regulations have been accurately applied within the set time frames.
- Authorise urgent medical claims and/or medical treatment at external medical providers within set SLAs. Procedures need to be reviewed regularly and, where required, escalate external provider trends to ensure our employees are given an excellent standard of medical care and internal support. Authorise approvals, reimbursements and direct billing invoice payments in-line with the applicable Medical Benefits Manual.
- Correspond and communicate via telephone, email or personal visits with covered members, doctors, internal stakeholders and external medical providers to discuss and resolve matters relevant to effective claim and pre-approval processing and business operations.
Specific to Projects
- Support the department with technical support to establish improved processes and system integration, design and create automated reports and dashboards to standardise management reporting.
- During project activity, verify all published material including but not limited to the MB Manual (T&Cs, Network list, Guide, Exclusions and TOB) group world site and MB SharePoint to ensure all entries are current and approved as per audit guidelines.
- Design and publish medical benefits customer communications such as insurance briefings, Info sheets, application forms or scheme updates ensuring they are clearly communicated and marketed to new or promoted employees, to make sure there is a clear understanding of the policy. Design and present other briefs to staff as appropriate. As part of the MB projects team maintain an up to date, easy to use internal SharePoint and customer group world page.
- Work with the Manager to recommend policy and process changes to improve efficiency, cost and quality across operations and assist the Manager in administering operating procedures and tariffs with external medical providers.
Qualifications & Experience
MINIMUM QUALIFICATIONS/EXPERIENCE/KNOWLEDGE/SKILLS
Experience:
Medical/Clinical/ Other Medical
Specific to Claims and pre-approval processing
Degree or Honours (12+3 or equivalent) - MBBS
Specific to Projects
Degree or Honours preferably (12+3 or equivalent) in a relevant medical field with relevant clinical experience. Any other additional non-healthcare experience is preferred.
Experience 4-5 yrs
Knowledge/skills:
Knowledge of claim examination procedures and standard insurance procedures.
Knowledge of medical terminology is desirable.
Knowledge of company insurance schemes and the reimbursement and benefits system would be an advantage.
Proficient in written and spoken English.
Computer literate and proficient in the MS Office Suite of Software with advanced Excel skills.
Preferred knowledge of web based tools such as SharePoint and Business Intelligence
Leadership Role : NO
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