Technical Specialist: Claims

Momentum Health; Bellville; On-site; ZAR 420,000 - 660,000; Full time

Job summary

Momentum Health seeks a skilled Business Operations/Technical Specialist to design, execute, and optimise automated procedures, generating accurate quality reports. You will provide technical expertise and guidance to enhance processes and drive efficiency through technology.

Requirements include a Matric, a relevant degree, 3-5 years in QA environments, and strong report-writing skills. You will support governance, audit activities, and stakeholder collaboration to improve service delivery and

Qualifications

• Matric or Grade 12 - Essential.
• A bachelor degree or equivalent qualification in a relevant field such as Computer Science, Information Technology, Engineering, or a related discipline - Desirable.
• 3 - 5 years relevant experience as a Business Operations Specialist/ Technical Specialist or equivalent area/role.
• Working experience within a quality assurance environment.

Responsibilities

• Provide high-quality business operation and technical support to maintain organisational processes, ensuring smooth operations.
• Apply innovative/creative thinking by identifying gaps, proposing solutions/enhancements, and presenting them to maximise process efficiency.
• Establish and nurture key relationships with internal and external stakeholders to facilitate collaboration and effective communication.
• Investigate and resolve any business escalations received, ensuring accurate and timely resolution to maintain operational effectiveness.
• Participate in external and internal audits, contributing to compliance and process improvement efforts.
• Assist in the drafting and maintenance of Quality Assurance Frameworks, ensuring they are up-to-date and aligned with requirements.
• Facilitating the effective training and development of staff to support consistent execution and high-quality outcomes
• Build data models based on stakeholder requirements to support data-driven decision-making.
• Collaborate with stakeholders to define reporting requirements and timeframes, delivering accurate reports as per agreed-upon standards.
• Compile and obtain appropriate sign-off for stakeholder reports, operational reports, and administrative reports to support decision-making.
• Provide technical assistance to QA and Governance staff, offering expertise and support as needed.
• Maintain an internal data and reporting repository for the Governance and Quality Assurance department, ensuring accessibility and data integrity.
• Responsible for user acceptance testing
• Managing and execution of projects

Skills

Communication

Analytical

Interpersonal

Multitasking

Problem solving

Root cause analysis

Collaboration

Business process improvement

Education

Bachelor's degree in Computer Science/IT/Engineering

Tools

Vitel

Oracle

Papertrail

KR1S

BI Tool

O2 health platform

Job description

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

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

Role Purpose

To design, execute, and optimise automated procedures, generating accurate reports on quality statistics, while providing technical expertise, support, and guidance to enhance processes and drive business efficiency through technology.

Requirements

• Matric or Grade 12 - Essential
• A bachelor degree or equivalent qualification in a relevant field such as Computer Science, Information Technology, Engineering, or a related discipline - Desirable
• 3 - 5 years relevant experience as a Business Operations Specialist/ Technical Specialist or equivalent area/role
• Working experience within a quality assurance environment

Knowledge

• In-depth understanding of claims assessing processes, including evaluating eligibility, appropriateness, and reimbursement based on policy guidelines, medical codes, and billing rules.
• 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.
• Knowledge of the legal framework and regulations, including the Medical Scheme's Act and related guidelines, ensuring compliance and adherence to regulatory requirements.
• Extensive knowledge of medical industry terminology, including medical conditions, procedures, treatments, and diagnostic coding (e.g., ICD-10), facilitating accurate claims assessment, effective communication with healthcare professionals, and appropriate code assignment.
• Specific understanding of operational processes within the healthcare industry, including case management, call center operations, and membership management, to effectively support operational requirements.
• Thorough understanding/proficiency of the operational system utilised within the quality assurance space (e.g., Vitel, Oracle, Papertrail, KR1S, BI Tool etc.).
• 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.
• Solid understanding of the medical aid industry's processes, regulations, and dynamics.

Skills

• Communication skills (written and verbal)
• Analytical skills
• Interpersonal skills
• Multitasking skills
• Problem solving skills
• Root cause analysis skills
• Collaboration skills
• Business process improvement skills

Duties & Responsibilities

PROCESS

• Provide high-quality business operation and technical support to maintain organisational processes, ensuring smooth operations.
• Apply innovative/creative thinking by identifying gaps, proposing solutions/enhancements, and presenting them to maximise process efficiency.
• Establish and nurture key relationships with internal and external stakeholders to facilitate collaboration and effective communication.
• Investigate and resolve any business escalations received, ensuring accurate and timely resolution to maintain operational effectiveness.
• Participate in external and internal audits, contributing to compliance and process improvement efforts.
• Assist in the drafting and maintenance of Quality Assurance Frameworks, ensuring they are up-to-date and aligned with requirements.
• Facilitating the effective training and development of staff to support consistent execution and high-quality outcomes
• Build data models based on stakeholder requirements to support data-driven decision-making.
• Collaborate with stakeholders to define reporting requirements and timeframes, delivering accurate reports as per agreed-upon standards.
• Compile and obtain appropriate sign-off for stakeholder reports, operational reports, and administrative reports to support decision-making.
• Provide technical assistance to QA and Governance staff, offering expertise and support as needed.
• Maintain an internal data and reporting repository for the Governance and Quality Assurance department, ensuring accessibility and data integrity.
• Responsible for user acceptance testing
• Managing and execution of projects

CLIENT

• Build and maintain relationships with clients and internal/external stakeholders, fostering trust and effective collaboration.
• Meet service level agreements with clients and stakeholders, managing expectations and delivering quality service.
• Make recommendations to improve client service and ensure fair treatment of clients within the area of responsibility.
• Contribute to a positive culture that prioritises relationships, feedback, and exceptional client service.
• Monitor turnaround times and quality standards, resolving issues promptly to enhance client service delivery.
• Drive client service delivery goals, aligning with predefined standards and providing appropriate advice and after-sales service.
• Manage client query processes, tracking and resolving queries accurately, and utilising them as opportunities for improvement.

PEOPLE

• Build strong relationships by providing specialist knowledge and leadership, fostering positive expectations.
• Continuously develop expertise in industry and subject matter, applying it effectively in the area of specialisation.
• Positively influence and manage change, offering specialist support when needed.
• Foster a culture of continuous innovation by developing, sharing, and implementing new ideas with colleagues and staff.
• Contribute to a work-centric thinking culture that emphasises productivity, service delivery, and quality management.
• Take ownership of driving career development, proactively seeking growth opportunities.

FINANCE

• Contribute to the development of area-specific budgets, minimising expenditure in alignment with operational plans.
• Identify cost-effective solutions and operational efficiencies to optimise financial resources.
• Implement and provide input into governance processes, systems, and legislation within the area of specialisation.
• Escalate unresolved policy and governance compliance issues for investigation and resolution.
• Provide input into the risk identification process and communicate recommendations in the appropriate forum.