Claims Operational Coach MMH261013-1

Momentum; Durban; On-site; ZAR 900,000 - 1,200,000; Full time

Job summary

Momentum is seeking an experienced Claims Operational Coach to develop and guide the claims handling team in achieving high performance, quality, and efficiency. You will oversee clinical risk management, provide technical training, and mentor staff to align business processes with service delivery objectives while maintaining rigorous quality assurance.

The role requires extensive knowledge of PMB legislation, scheme rules, and regulatory requirements, plus strong stakeholder engagement with

Qualifications

• Matric and a relevant degree/diploma are advantageous.
• Continuous professional development in Healthcare, Medical Aid Administration, or Leadership programmes advantageous.
• Experience in a Medical Aid Claims environment is essential.

Responsibilities

• Coach and mentor the Claims Team to improve productivity, quality and service delivery.
• Lead claims-related training and ongoing knowledge sharing sessions.
• Ensure quality assurance of claims processing and adherence to standards.
• Drive process improvements to reduce turnaround times and increase accuracy.
• Act as the QMS Champion for the Claims Department and ensure compliance.
• Identify and address compliance risks and support audits and governance.

Skills

Coaching

Leadership

Stakeholder management

Quality assurance

Process improvement

Training & development

Mentoring

Education

Matric (Grade 12)

Relevant Degree or Diploma in Healthcare/Business Administration

Tools

Oracle 1

Oracle 2

Excel

Word

Outlook

Job description

Role Purpose

A Claims Operational Coach typically supports and develops claims handling teams, focusing on improving performance, quality, and efficiency. This role involves coaching, training, and providing guidance to claims professionals, ensuring they meet performance targets and adhere to company policies and procedures.

To oversee clinical risk management, technical training, mentoring, and ensuring alignment between business processes and service delivery objectives, whilst maintaining quality assurance and addressing skill gaps within the team.

Qualifications

• Matric (Grade 12)
• Relevant Degree or Diploma in Healthcare, Business Management/Administration or related field will be advantageous
• Continuous professional development plan in Healthcare, Medical Aid Administration, or Leadership programmes will be advantageous

Experience

• Minimum 5 - 10 years' experience within a Medical Aid Claims environment
• Proven experience in the assessment of medical aid claims (Paper and/or EDI)
• Experience in coaching, mentoring, or leading a claims team
• Prior experience using Oracle 1 and Oracle 2 systems
• Experience interacting with healthcare providers, schemes, CMS and other stakeholders

Technical Knowledge

• Sound understanding of medical aid claims administration processes
• Comprehensive knowledge of PMB legislation and industry requirements
• Knowledge of Scheme Rules and benefit interpretation
• Understanding of NHRPL (BHF) and SAMA tariffs
• Knowledge of Quality Management Systems (QMS)
• Knowledge of regulatory and compliance requirements applicable to medical schemes
• Proficiency in Microsoft Office, particularly Excel, Word and Outlook

Duties and Responsibilities

Leadership and Coaching

• Coach and mentor the Claims Team to improve productivity, quality, and customer service delivery.
• Conduct regular one-on-one coaching sessions and performance discussions.
• Develop individual improvement plans for underperforming staff.
• Promote employee engagement and create a high-performance culture.
• Draft and training content and standard operation document (SOPs).

Training and Development

• Identify skills gaps through performance analysis and quality reviews.
• Facilitate claims-related training and ongoing knowledge-sharing sessions.
• Support onboarding and development of new and current employees.
• Drive continuous learning initiatives within the team.

Claims Quality Assurance

• Monitor claims assessment of quality and compliance with established standards.
• Conduct quality audits and provide constructive feedback.
• Ensure accurate application of scheme rules, PMB requirements, and tariff structures.
• Drive initiatives aimed at improving first-time claim accuracy.

Process Improvement

• Identify operational inefficiencies and recommend process enhancements.
• Implement initiatives aimed at improving turnaround times, productivity, and quality.
• Develop, review, and maintain Standard Operating Procedures (SOPs).
• Ensure process documentation remains current and effect

QMS Ownership

• Act as the Claims Department QMS Champion.
• Drive compliance with quality management requirements.
• Participate in quality assessments and internal audits.
• Track and implement corrective actions where required.

Compliance and Risk Management

• Ensure adherence to Scheme Rules, PMB legislation, and internal operating procedures.
• Monitor and address compliance risks within the claims environment.
• Ensure accurate handling of escalated claims and exceptions.
• Support audit and governance requirements.

Stakeholder Management

• Manage and resolve escalated claims queries.
• Engage effectively with healthcare providers, hospitals, schemes, CMS and internal stakeholders.
• Maintain professional relationships to support operational objectives.
• Communicate operational challenges and solutions effectively.

Reporting and Analytics

• Analyse claims data and identify trends.
• Prepare management reports relating to:
  • Productivity
  • Turnaround Times
  • Quality Scores
  • Escalations
  • Training Interventions
  • Error Trends
• Provide recommendations based on data analysis to improve business performance.