Overview
Query Resolution Team Leader MMH260324-10 Jobs in Durban, KwaZulu-Natal, South Africa at Momentum
Title: Query Resolution Team Leader MMH260324-10
Company: Momentum
Location: Durban, KwaZulu-Natal, South Africa
Role Purpose
Accountable for the day to day operations relative to the overall management of escalated and resolution of queries regarding claim related issues. Ensures that claims are paid as per the schemes rules and policies. Maintaining of service level agreements. Responsible for recommending strategic initiatives to enhance claims and auditing processes and procedures. Ensure operational efficiency and management of resources.
Requirements
- Completed Degree OR currently studying toward a relevant Degree is essential.
- At least 10 years of experience in the medical aid environment
- Minimum 3–5 years proven leadership or management experience
- Has held a management position dealing with staff for at least 5 years
- 5 years with in the claims and claims query processing area
- Excellent understanding and proficiency in the medical aid industry
- Additional clinical knowledge and or exposure to managed health care principal would be an advantage
- Sound understanding of medical aid tariffs, modifiers and there application.
- Excellent knowledge and understanding related to claims processes
- Excellent knowledge and understanding of tariffs, ICD10 and CPT codes
- Good accounting knowledge
- Oracle system preferred
- Excellent excel skills
Duties and Responsibilities
Internal Process
- Enhancements to processes and systems
- Creates and updates process documents related to process and audit processes and the sharing of these documents
- Minutes of meetings/projects
- Investigation of high level escalations –providing feedback to management
- Assisting the provider network department in regard to providers escalation that may require recon
- Stale claim analysis and report feedback
- Managing the pathology credit process.
- Liaising with the finance department in regard certain debt processes
- Correct application of policies and regulations
- Payment of valid claims
- Monitor service level agreements and reports
- Monthly Stats reports and providing feedback in regard to interpretation of the variances
- Manage weekly discipline reports
- Complete performance reviews
- Ensure accuracy of claims payment
Enable client centricity within area of responsibility
(Client Services)
- Provide authoritative, expertise and advice to clients and stakeholders
- Build and maintain relationships with clients and internal and external stakeholders
- Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments
- Define service practices which builds rewarding relationships, encourages innovation and allows others to provide exceptional client service.
- Deliver on service level agreements made with 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.
Effectively lead team
(People)
- Create a positive work climate and culture to energise employees, give meaning to work, minimise work disruption and maximise employee productivity.
- Demonstrate exemplary leadership behaviour, through personal involvement, commitment and dedication in support of organisational values.
- Select and recruit suitably qualified talent in line with Employment Equity principles and MMI values
- Drive a culture that guides and directs best practice, fostering an environment of continuous learning, improvement and cohesiveness.
- Enable a learning and growth culture whereby information regarding successes, issues, trends and ideas are actively shared between team members.
- Execute effective workforce planning practices to ensure that staffing requirements are accurately forecasted
- Identify employee growth and development needs and schedule interventions to enable ongoing development, training and personal growth.
- Effectively manage performance within the team in order to ensure business objectives are achieved.
Manage budget and implement sound financial controls
(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
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