Key Responsibilities:

Full Management of the of the Authorisations Teams (Health and Pet):

• Define the claims strategy that can be cascaded down for successful implementation across the claims function.
• Structure the Claims department to enable high-level claims analysis to be carried out and successfully interpreted by top management.
• Responsible for establishing a claims environment and helping to solidify the brands reputation in the market.
• Create and implement claims processes that will enable the Company to effectively service its clients in such a way it creates competitive advantage for the business.
• Responsible for managing claims staff who will assist in the day-today operations of the business.
• Oversee the entire insurance authorisation process for all authorisations day to day and hospital services, including surgeries, treatments, and diagnostic procedures.
• Overseeing and ensuring all necessary documentation, including medical records, is submitted accurately and in a timely manner.
• Ensuring productivity and execution of authorisations are done timeously.
• Resolve issues with denied claims, claim queries or delayed authorisations.
• Manage hospital authorisation and claims process.
• Review authorisations.
• Case management audits.
• Attend to after-hours authorisation queries.
• Manage a significant number of personnel and oversees resource management activities.
• Support Authorisations team when volumes dictate.
• Advise on clinical protocols as required, based on terms and conditions.
• Ensure events and claims limit are linked correctly.
• Manage client/provider satisfaction.
• Manage ex-gratia request process.
• Assist with Ombudsman complaints.
• Oversee and investigate fraud and report on all cases to the Compliance Department.
• Manage the entire claims processing function and be accountable for the success thereof.
• Ensure claims processes align with audit requirements.
• Review loadings based on financial risk with application.
• Manage change in health / pet status and amend accordingly.
• Maintain, analyse and make appropriate changes to ensure maintenance of claims ratios.
• Manage the entire claims processing function and be accountable for the success thereof.
• Research claim payment issues.
• Coordinates activities closely with other department managers and staff
• Responsible for the delivery of the KPIs of team including quality, productivity and compliance parameters.
• Delivers regular and timely coaching and feedback to the team to enhance performance.
• Ensures proper and timely dissemination of all processes and business updates to the team, based on client requirements.
• Accountable for analysing known best practices for continuous improvement.
• Responsible for the enforcement of policies and procedures to ensure compliance.
• Analyses the performance by reviewing the statistics on performance and address improvements.
• Hires and trains claims processing staff and develops job descriptions.
• Monitors and evaluates the performance of staff.
• Other duties as assigned from time to time.

SOP Management of claims

• Developing and generating all SOP’s within the Health product environment and ensuring that they are updated when changes occur.
• Maintain and train staff on internal SOP’s to ensure consistency and accuracy in respect of policy changes/updates,
• Compile underwriting strategy in conjunction with premium development.
• Ensure all corrections are done timeously and accurately in line with “live” underwriting turnaround times,
• Ensure underwriting processes align with all audit requirements,
• Become a product knowledge expert and advise on relevant product development and amendments.
• Assist with implementing risk protocols/policy wording.

Compliance Claims (Health and Pet):

• Ensure Compliance requirements are implemented and maintained aligned to Council of Medical Schemes.
• Ensuring that the department functions in accordance with the Compliance requirements of the product and the claims at all times to reduce any risk factors. 

Provider relations

• Managing and ensure all service provider relationships are maintained at the highest satisfactory level possible and ensuring regular service provider engagements occur.

Vendor Management

• Managing and ensuring all vendor relationships are maintained at the highest satisfactory level possible and ensuring regular vendor engagements occur in order to maintain relations. 

Claims AI process integration

• Should have experience within AI integration related to the insurance industry product implementation.
• Ensuring the process implementation is managed in accordance with defined processes and ensuring integration is seamless.

Competitor comparatives

• Conduct trend analysis on claim types and volumes and provide valuable insight to the Financial Director
• Supply and maintain competitor analysis and ensure that premiums and product are market related.

Full Gap product management

• Managing of the Gap product and the management of the submissions of claims.

 Group Schemes

• Managing of the Groups scheme benefits and processing of the claims aligned to these with overseeing the brokers.
• Ensuring all Group claims are processed timeously without unnecessary delays.

Product design and updates

• Ensure claims processes align with audit requirements.
• Review loadings based on financial risk with application.
• Manage change in health status and amend accordingly.
• Maintain, analyse and make appropriate changes to ensure maintenance of claims ratios.

Training – Department and HR material reviews

• Ensuring any updates are amended with HR and training to the Policy schedules and material amendments.
• Ensuring all amendments are carried through to training and material updates of the product schedules to reduce risk for the Company on the products.

Succession planning management

• Developing and maintaining succession planning for employees and ensuring succession of employees within the department.
• Ensuring continues development programs are in place with the aim at advancing employees skills and ability.

Leadership and Direction

• Providing vision and direction to team members
• Through effective inspirational leadership, facilitate the creation of accountable, full-claims teams who understand and strive to meet the needs of all stakeholders.
• Role model behaviour and motivate team members in line with the core values.
• Take full responsibility for performance of all direct reports, motivating and managing them in relation to quality standards and agreed benchmarks and objectives, focusing on all aspects of sound people management.
• Provide support and guidance on career path planning, on-the-job training, coaching, and mentoring to direct reports.
• Leads change to creates a self-refreshing and learning organisation.
• Continuous improvement of business processes.

Work collaboratively

• Build a culture of respect and understanding across the organisation.
• Recognise outcomes which resulted from effective collaboration between teams.
• Build cooperation and overcome barriers to information sharing, communication, and collaboration across the organisation.
• Facilitate opportunities to engage and collaborate with internal and external stakeholders to develop joint solutions.

Self-Management

• Follow through to ensure that personal quality and productivity standards are consistently and accurately maintained.
• Demonstrate consistent application of internal procedures.
• Plan and prioritise, demonstrating abilities to manage competing demands.
• Demonstrate abilities to anticipate and manage change.
• Demonstrate flexibility in balancing achievement of own objectives with abilities to understand and respond to organizational needs.

Requirements

Desired Skills & Experience:

Education:

• Grade 12 / Matric
• Relevant medical qualification (Preferred) – Nursing Degree/Doctorate
• Bachelor of science (BSc), bachelor’s degree in business financial administration (BCom) and or Business Management Degree / Qualification (NQF5) or a related field, would be preferable and advantageous.
• Minimum 6 – 8 years industry experience (Preferred).
• Medical workplace experience working within a medical centre of no less than 2-3 years.
• Additional certifications in healthcare management or insurance billing will be advantageous.

Experience:

• 5- 10 years of experience in medical healthcare administration, including at least 2 years in an insurance authorisation or billing role.
• Proven experience managing a team within a medical healthcare setting.
• In-depth knowledge of medical health insurance policies, reimbursement processes, and authorisation procedures is essential.
• Familiarity with medical service and hospital administrative processes linked to insurance claim systems.
• Proficient in office management software and Microsoft Office Suite.
• Strong organisational and leadership skills.
• Excellent communication and interpersonal abilities.
• Ability to multitask and prioritize effectively in a fast-paced environment.
• Problem-solving skills and attention to detail.
• Highly administrative and accurate in execution of tasks.
• Proven experience as an Admin Manager or in a similar role, including motivating of staff and ensuring the team is highly productive.