Main purpose of the job
Clinical Risk Management by underwriting, authorisation according to protocol, case management and claim auditing. Provide support and education to clients/providers relating to claims and claim queries. Project a professional company image through customer/provider interaction. Provide support and education to clients and appropriate vendors/providers relating to claims/clinical queries, processes, and the policy. Project a professional company image through omni channel interaction.
Claims Assessing and Claims Authorisation
- Authorization of Hospital (primarily), Day-to-day and/or all related claims as per policy terms and conditions and standard protocol.
- Working 12 hour shifts inclusive of weekends/public holidays/nights as per scheduling
- Inform customers/providers regarding invoices what will not be accepted or specific claim requirements via appropriate methods (email/ telephonically).
- Answer phones and respond to customer requests within the determined SLA.
- Explain products and update customer details in computer system.
- Provide customers with product and service information via appropriate methods (email/ telephonically).
- Follow and adhere to claims/company processes, procedures, and protocol.
- Recognize, document, and alert the supervisor of trends in customer calls/claims.
- Recommend process improvements.
- Focus on first call resolution as far as possible.
- Transfer customer calls to appropriate staff/department, where necessary
- Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim
- Daily updates: Ensure daily stats are updated and sent to supervisor/ manager at the end of each day. This includes ssubmission of all relevant reports, paperwork and updates on all claims activity as directed, in a timeous manner.
- Assessing of claims according to standard operating procedure and company protocols
- Improve client service experience, create engaged clients, and facilitate organic growth
- Manages tasks allocated through omni-channel platforms
- Handle complex and escalated client service issues
- Build/maintain rapid channel of communication to client in case of service-related issues and events
- Represent the “Voice of the Customer”
- Create a culture of Customer/Client Centricity
- Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Supervisor.
- Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
- Leverage team success to drive all initiatives and experiences with clients.
- Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
- Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client’s queries from end-to-end to ensure a world class client service experience.
- Support cross functional work areas targeted to resolve issues raised by clients.
- Proactively gather client feedback to optimize client experience
Underwriting
- Underwriting according to protocol and to ensure effective risk management
- Accurately Underwriting of new dependents, underwriting according to protocol and to ensure effective risk management
Additional tasks
- Be available and willing to assist with any additional tasks and projects, as required by the department
- Reviewing/capturing/assessing of specialized claims including but not limited to disability, dread, death and repatriation.
- Reviewing clinical guidelines/SOPs as required
Claims Queries
- Identify, research, and resolve customer issues.
- Follow-up on customer enquiries not immediately resolved, within determined SLA’s.
- Educate clients on claims process as required.
- Assist and resolve claim queries and client complaints (telephonically/emails)
Quality, Consistency and Compliance
- Maintain QA call metrics as defined by the business
- Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
- Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
- Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
- Ensure quality assurance standards are met as per company guidelines.
- Ensure adherence to all relevant legislation and regulations as set out by the Company, Regulatory Board, and the Financial Services industry.
Work Collaboratively
- Build a culture of respect and understanding across the organisation
- Recognise outcomes which resulted from effective collaboration between teams
- Build cooperation and overcome barriers to information sharing, communication, and collaboration across the organization
- Facilitate opportunities to engage and collaborate with internal and external stakeholders to develop joint solutions
Self-Management
- Follow through to ensure that personal quality and productivity standards are consistently and accurately maintained
- Demonstrate consistent application of internal procedures
- Plan and prioritise, demonstrating abilities to manage competing demands
- Demonstrate abilities to anticipate and manage change
- Demonstrate flexibility in balancing achievement of own objectives with abilities to understand and respond to organizational needs
