Role Purpose Responsible for configuring the O2 System accurately as well as ensuring timely implementation and maintenance of critical information. Ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements. Administers and maintains the platform for all schemes and insurances that are currently administered by Momentum Health to ensure that the admin and Managed Care components are up to date, so that the Momentum Health Schemes and Insurance products are functioning as per the design intent accurately and efficiently. Requirements Matric or Grade 12 Associated Degree or equivalent combination of education and experience 5 to 7 years Healthcare experience In depth medical aid industry knowledge – Essential A good understanding of how medical aid administration operates (including and not limited to the benefit structure and medical terminology) – Essential Good knowledge of file formats and reporting tools – Advantageous Good knowledge of tariffs and the government gazette – Essential Process Analyze and interpret data to determine appropriate configuration changes. Accurately interprets specific Scheme benefits, contracts as well as additional business requirements and converts these terms to configuration parameters. Validates coding, updates and maintains benefit plans, provider contracts, fee schedules and various system tables through the user interface. Applies previous experience and knowledge to verify the accuracy of updates to claim/encounter and/or system updates as necessary. Works with fluctuating volumes of work and prioritises work to meet deadlines and departmental needs. Reviews documentation regarding updates/changes to member enrolment, provider contract, provider demographic information, claim processing guidelines and/or system configuration requirements, evaluating the accuracy as applied to the appropriate modules within the core processing system (O2). Conducts audits on samples of processed transactions impacted by these updates/changes, ensuring all outcomes align with the original documentation and allow appropriate processing. Documents audit results and makes recommendations as necessary. Researches and tracks the status of unresolved errors issued on daily transactional audits, communicating with Core Operations Functional Business Partners to ensure resolution within 10 days of error issuance. Helps evaluate the adjudication of claims using standard principles and specific policies and regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims. Prepares, tracks, and provides audit findings reports according to designated timelines. Presents audit findings and makes recommendations to management for improvements based on audit results. Provides input from a system perspective into the year‑end process, new projects, system failures, file failures and claims errors. Acts as the escalation point for the business and IT. Investigates escalations regarding ERAs to providers (electronic remittance advice). Provides the initial system set‑up for new schemes and options. Updates and creates tariffs, limits and rules on the online system, liaising with fund and provider negotiations. Updates and creates limits, templates, events and rules on the online system (including updates to modifiers, unit and rate tables), liaising with Fund, Corporate Governance and auditors. Conducts claims testing to avoid financial loss to the business. Processes exceptions on Kr1s reports to ensure that schemes are protected against possible losses by each change made on the live system. Generates, analyzes and communicates claims impact to the business to ensure the most feasible decision is taken. Liaises with the business regarding system impact, claims impact and feasibility of business requests. Participates in Scheme audit processes with zero audit findings. Documents Masterfiles and other business‑related processes, improving masterfile processes and related business processes. Initiates continuous improvement, enhancements and innovative change initiatives in the working environment (including and not limited to the system). Handles escalations competently and provides ongoing feedback until resolution. Creates test packs for new development items and initiates testing and sign‑off. Monitors all interfacing and keeps the business informed where required. Liaises with third parties when required. Sets up email to bin, provides system access for users on Oracle (to live and test systems). Updates statement messages for suppliers/members. Loads scheme rates, negotiated rates and UPFS rates. Updates and creates network rules, network providers, policy rules and claim payment rules. Manages NAPPI updates or manual pricing updates. Updates for GP profiling quarterly and pharmacy profiling quarterly. Assists with solving business helpdesk queries/calls logged. Client Provides authoritative expertise and advice to clients and stakeholders. Builds and maintains relationships with internal and external clients. Delivers on service level agreements made with internal and external clients to ensure expectations are exceeded. Recommends improvements to client service and fair treatment of clients within the area of responsibility. Contributes to a culture that builds rewarding relationships, facilitates feedback, and provides exceptional client service. People Develops and maintains productive and collaborative working relationships with peers and stakeholders. Positively influences and participates in change initiatives. Continuously develops own expertise in professional, industry and legislative knowledge. Contributes to continuous innovation through development, sharing and implementation of new ideas. Takes ownership for driving career development. Works independently to complete tasks. Finance Contributes to the financial planning process within the area (e.g., maintaining telephone and internet usage). Identifies opportunities to enhance cost effectiveness, increase operational efficiency and continuous improvement. Manages financial and other company resources under your control with due respect. Provides input into risk identification processes and communicates recommendations in the appropriate forum. #J-18808-Ljbffr