Role Purpose Accountable for clinical risk management, technical training, configuration management, mentoring and skills development in line with departmental and individual objectives and ensuring that the business processes and system capabilities are aligned to service delivery. Requirements Qualifications Matric certificate 3-5 years of experience in Managed Health Care is essential Qualification as a Registered Nurse and registered with SANC is essential Knowledge & Experience Knowledge of the NHRPL - National Health Reference Price List and SAMA tariff codes, ICD10, CPT (CCSA) coding Claims Assessing experience Training or coaching qualifications In depth understanding of claims assessing processes, including evaluating eligibility, appropriateness, and reimbursement based on policy guidelines, medical codes, and billing rules Knowledge of the legal framework and regulations, including the Medical Schemes Act and related guidelines, ensuring compliance and adherence to regulatory requirements Extensive knowledge of medical industry terminology, including NAPPI codes, medical conditions, procedures, treatments, and diagnostic coding (e.g, ICD10), facilitating Proficient knowledge of various medical scheme benefit designs, coverage levels, limitations, and exclusions for accurate claims assessment and reimbursement determination Comprehension and interpretation of billing rules governing medical claims processing, along with familiarity with relevant systems and technologies used for claims adjudication Specific understanding of operational processes within the healthcare industry, including case management, call center operations, and membership management, to effectively support operational requirements Proficiency in working with O2 or similar health insurance platforms to process claims, manage member information, and generate reports for analysis and decision making Strong proficiency in using Microsoft Word and Excel for documentation, data analysis, and report generation, ensuring accuracy and clear presentation The ability to interpret and apply scheme rules correctly Sound communication skills (both written and verbal) Duties and Responsibilities Internal Process Instruct, train and coach business team members and service managers on Products, Systems and Processes Updating department process documents and process library annually Responsible for up to date accurate training material that will help employees understand the subject matter Liaise with trainers to ensure that their training material is accurate and continuously updated Create new and amend existing billing rules as per business requirements Review clinical master files annually and on a adhoc basis relating to but not limited to tariff, ICD10 and CCSA codes Communicate effectively with healthcare professionals, and appropriate code assignment Facilitates and manages system enhancements and changes Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed Develop and maintain productive and collaborative working relationships with peers and stakeholders Positively influence and participate in change initiatives Continuously develop own expertise in terms of professional, industry and legislation knowledge Client Build and maintain relationships with clients and internal and external stakeholders Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed Make recommendations to improve client service and fair treatment of clients within area of responsibility Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes People Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation Positively influence and manage change and offer specialist support where required Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management Take ownership for driving career development Finance Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans Identify solutions to enhance cost effectiveness and increase operational efficiency Implement and provide input into governance processes, systems and legislation within area of specialisation Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes Provide input into the risk identification processes development and communicate recommendations in the appropriate forum #J-18808-Ljbffr