Talent Pool : Configuration Specialist Mmh251205-4

Momentum; Gauteng; On-site; ZAR 300 000 - 400 000; Full time

Job summary

A leading health services company in Gauteng is looking for a Configuration Specialist to ensure efficient configurations of the O2 system and maintain critical information. The role requires 5 to 7 years of healthcare experience and in-depth knowledge of the medical aid industry. Major responsibilities include validating coding, conducting audits, and providing expert advice to clients. This full-time, mid-senior level position offers an opportunity to contribute to system improvements in a collaborative environment.

Qualifications

• 5 to 7 years Healthcare experience.
• Good understanding of medical aid administration.
• Knowledge of tariffs and government regulations.

Responsibilities

• Configure the O2 System effectively and accurately.
• Validate coding and maintain benefit plans.
• Conduct audits on processed transactions.
• Provide authoritative advice to clients and stakeholders.

Skills

Healthcare experience

In depth medical aid industry knowledge

Knowledge of medical aid administration

Knowledge of file formats and reporting tools

Knowledge of tariffs and government gazette

Education

Matric or Grade 12

Associated Degree or equivalent

Job description

Talent Pool: Configuration Specialist MMH

Momentum Centurion, Gauteng, South Africa

Role Purpose

Responsible for configuring the O2 System accurately as well 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 admin and Managed Care components are up to date to ensure 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
• 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

Duties and Responsibilities

Analyze and interpret data to determine appropriate configuration changes.

Accurately interprets specific Scheme benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.

Validates coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.

Apply previous experience and knowledge to verify accuracy of updates to claim / encounter and / or system update(s) as necessary.

Works with fluctuating volumes of work and is able to prioritize work to meet deadlines and needs of department.

Reviews documentation regarding updates / changes to member enrolment, provider contract, provider demographic information, claim processing guidelines and / or, system configuration requirements.

Evaluates the accuracy of these updates / changes as applied to the appropriate modules within the core processing system (O2).

Conducts audits on samples of processed transactions impacted by these updates / changes.

Determines that all outcomes are aligned to the original documentation and allow appropriate processing.

Clearly documents the audit results and makes recommendations as necessary.

Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 10 days of error issuance.

Helps to 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.

The escalation point for the business and IT

Investigates escalation regarding ERA"s to providers (electronic remittance advise).

Provides the initial system set up for new schemes and options.

Updates and creates tariffs, limits and rules on the on-line system - liaises with fund and provider negotiations.

Updates and creates limits and templates, events and rules on the on-line system (includes update to modifiers, unit and rate table) liaises with Fund, Corporate Governance and auditors.

Conducts claims testing to avoid financial loss to the business.

Actions exceptions on Kr1s reports to ensure that the scheme / s are protected against possible losses by each change made on the live system.

Generates, Analyses and communicates claims impact to the business, to ensure the most feasible decision is taken.

Liaises with the business in terms of system impact, claims impact and feasibility of business requests.

Participates with Scheme audit process with a zero audit finding result.

Documenting of Masterfiles and other business related processes.

Process improvements to masterfiles processes and other business related processes.

Initiates continuous improvement / enhancements and Innovative change initiatives in working environment (including and not limited to the system.

Handles escalations competently and provide ongoing feedback until conclusion of escalation.

Create test packs for new development items and initiate testing and sign-off.

Monitor all interfacing and keep business informed where required.

Liaise with third parties when required.

Setting up email to bin, providing system access for users on oracle (to the live and test systems).

Updating statement messages for suppliers / members.

Loading of 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.

Assist 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 in order to ensure that expectations are exceeded.

Make recommendations to improve client service and fair treatment of clients within area of responsibility.

Participates and contributes to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.

People

Develops and maintains productive and collaborative working relationships with peers and stakeholders.

Positively influence and participate in change initiatives.

Continuously develops own expertise in terms of professional, industry and legislation knowledge.

Contributes to continuous innovation through the 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 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 the risk identification processes and communicate recommendations in the appropriate forum.

Seniority level

Mid-Senior level

Employment type

Full-time

Job function

Human Resources

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