Main purpose of the Job
To ensure that all Gap claims are accurately captured into the iMed system.
Position Specific Outputs
- Duplicate check claims received, and process claims and emails according to processes.
- Capture all claims received in accordance with relevant legislation and processes.
- Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
- Providing coding review and resolution on call centre queries
- Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
- Communicate with Stake holders
- Maintain clinical documents and processes
- Review and action QA reports and provide corrective actioning
- Assist with training and sharing of knowledge within the team and clients
- Assist on the various Call centres
- Assist with call centre call backs.
- Review and assess gap claims.
- Verify documentation and ensure all required information is completed.
- Communicate with clients and stakeholders to gather necessary information.
- Process claims efficiently and accurately.
- Maintain detailed records of claims and assessments.
- Collaborate with other departments.
- Assist with departmental Adhoc duties where required.
Operating Model:
- Conduct accurate and effective intervention/reconciliation of administration on all allocated claims.
- Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement.
- Continuously apply relevant rules.
- Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims.
- Rectify incorrect information on claims and escalate where required.
- Reconcile claims where required and communicate outcome.
- Ensure correct payments to vendor or member.
- Meet delivery objectives through working with other team members within and linked to the department / project.
- Resolve operational performance variations and problems and escalate unresolved issues to higher levels.
- Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery.
Operational Implementation of Strategy:
- Keep up to date with operational changes implemented in response to important external influences
- Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
- Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement
Operational Leadership:
- Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
- Engage in development, coaching and mentoring
- Support transformation through valuing diversity
- Behave in alignment with the Afrocentric values
Stakeholder Management:
- Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies.
- Identify, investigate, respond to and refer IT assessing queries appropriately.
- Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved.
- Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in.
