Claims Query Resolution Team Leader

Momentum Health; Sandton; On-site; ZAR 700,000 - 1,050,000; Full time

Job summary

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings, seeks a Lead to manage the claims team and resolve client queries, ensuring claims are processed to meet business expectations and superior client experience.

The role requires 4–6 years in claims management, 1–2 years of people management, and solid insurance industry knowledge, including medical aid tariffs and coding standards. Oracle and Excel skills are advantageous.

Qualifications

• 4–6 years of claims management and claims query processing experience.
• Completed degree or currently studying towards one.
• 1–2 years people management experience.
• Experience in the insurance/related industry.
• Strong knowledge of medical aid tariffs and modifiers.
• Familiarity with ICD-10 and CPT coding.
• Good accounting knowledge.
• Excel proficiency; Oracle experience preferred.

Responsibilities

• Enhance processes and update related documentation.
• Investigate escalations and provide feedback to management.
• Ensure accurate claims payment and monitor SLAs.
• Provide accurate information and after-sales service to clients.
• Build and maintain relationships with clients and stakeholders.
• Support financial planning and resource management.
• Contribute to continuous innovation and career development.

Skills

Claims management

People management

Insurance industry

Medical aid knowledge

ICD-10 & CPT codes

Accounting knowledge

Oracle

Excel

Education

Degree (completed or in progress)

Tools

Oracle

Job description

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose Lead and manage the claims team to resolve client queries and process claims aligned to business expectations and aligned to desired client experience.

Requirements

• 4-6 years experience in claims management and claims query processing area (essential)
• Completed Degree or studying towards a degree would be an advantage
• 1-2 years people management experience (essential)
• Experience in the insurance / related industry (essential)
• 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 & 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
• Investigation of high-level escalations –providing feedback to management
• Stale claim analysis and report feedback
• 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
• Complete performance reviews
• Ensure accuracy of claims payment
• Enable client centricity within area of responsibility

CLIENT

• Provide accurate information and advice to clients and stakeholders in order to ensure that the client receives the appropriate after sales services.
• Provide regular reports on delivery of services against agreed service level agreements and in terms of overall customer targets.
• Provide authoritative, expertise and advice to clients and stakeholders.
• Build and maintain relationships with clients and internal and external stakeholders.
• 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.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.

PEOPLE

• 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.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas.
• Take ownership for driving career development.

FINANCE

• Contribute to the financial planning process within area Identify opportunities to enhance cost effectiveness and increase operational efficiency.
• Manage financial and other company resources under your control with due respect.
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

Adopting Practical Approaches: Applies practical skills when investigating issues prefers to learn by doing is practically minded and applies common sense,

Generating Ideas: Is creative in producing ideas assumes an original approach when generating ideas adopts radical solutions,

Developing Strategies: Is focused on developing strategies thinks in the longer term and anticipates trends envisages the future and adopts a visionary approach,

Making Decisions: Is determined and decides on actions willingly assumes responsibility is definitive and stands by own decisions,

Directing People: Is comfortable leading people coordinates and directs groups seeks to control things,

Empowering Individuals: Motivates individuals by empowering them seeks to inspire people and groups gives encouragement to others,

Upholding Standards: Behaves ethically and justly is discreet and maintains confidentiality meets commitments by acting with integrity,

Producing Output: Is focused on activity and works quickly keeps busy and maintains productivity is comfortable multi:tasking to produce output,