Main purpose of the job
Clinical Risk Management by underwriting, authorisation according to protocol, case management and claim auditing. Provide support and education to clients/providers relating to claims and claim queries. Project a professional company image through customer/provider interaction. Provide support and education to clients and appropriate vendors/providers relating to claims/clinical queries, processes, and the policy. Project a professional company image through omni channel interaction.
Claims Assessing and Claims Authorisation
Authorization of Hospital (primarily), Day-to-day and/or all related claims as per policy terms and conditions and standard protocol.
Working 12 hour shifts inclusive of weekends/public holidays/nights as per scheduling
Inform customers/providers regarding invoices what will not be accepted or specific claim requirements via appropriate methods (email/ telephonically).
Answer phones and respond to customer requests within the determined SLA.
Explain products and update customer details in computer system.
Provide customers with product and service information via appropriate methods (email/ telephonically).
Follow and adhere to claims/company processes, procedures, and protocol.
Recognize, document, and alert the supervisor of trends in customer calls/claims.
Recommend process improvements.
Focus on first call resolution as far as possible.
Transfer customer calls to appropriate staff/department, where necessary
Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim
Daily updates: Ensure daily stats are updated and sent to supervisor/ manager at the end of each day. This includes ssubmission of all relevant reports, paperwork and updates on all claims activity as directed, in a timeous manner.
Assessing of claims according to standard operating procedure and company protocols
Improve client service experience, create engaged clients, and facilitate organic growth
Manages tasks allocated through omni-channel platforms
Handle complex and escalated client service issues
Build/maintain rapid channel of communication to client in case of service-related issues and events
Represent the "Voice of the Customer"
Create a culture of Customer/Client Centricity
Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Supervisor.
Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
Leverage team success to drive all initiatives and experiences with clients.
Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client's queries from end-to-end to ensure a world class client service experience.
Support cross functional work areas targeted to resolve issues raised by clients.
Proactively gather client feedback to optimize client experience
Underwriting
Underwriting according to protocol and to ensure effective risk management
Accurately Underwriting of new dependents, underwriting according to protocol and to ensure effective risk management
Additional tasks
Be available and willing to assist with any additional tasks and projects, as required by the department
Reviewing/capturing/assessing of specialized claims including but not limited to disability, dread, death and repatriation.
Reviewing clinical guidelines/SOPs as required
Claims Queries
Identify, research, and resolve customer issues.
Follow-up on customer enquiries not immediately resolved, within determined SLA's.
Educate clients on claims process as required.
Assist and resolve claim queries and client complaints (telephonically/emails)
Quality, Consistency and Compliance
Maintain QA call metrics as defined by the business
Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
Ensure quality assurance standards are met as per company guidelines.
Ensure adherence to all relevant legislation and regulations as set out by the Company, Regulatory Board, and the Financial Services industry.
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 organization
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
Minimum Academic, Professional Qualifications & Experience required for this position
Grade 12 with English and a second language
Relevant clinical qualification in related field advantageous (international nursing/medical provider qualifications will be considered whilst awaiting interim registration in SA)
Customer Service or Medical claims experience advantageous
Functional Competencies
Literacy – Have excellent reading, writing and interpersonal skills
Pc Literacy – In-depth knowledge of Word, excel, email and Internet
Ability to respond according to TAT
Client Relationship Management
Maximise Service Performance
Query Resolution
Build & Develop Client Centric Capabilities
Deliver on Client Expectations
Knowledge Sharing
Driving Excellence through Client Experience
Ability to be effective in a pressurised environment
Ability to meet deadlines within time constraints
Essential
Evaluating Problems
Investigate Issues
Problem Solving
Building Relationships
Communicating Information
Showing Resilience
Adjusting to Change
Giving Support
Accurately Processing Details
Structuring Tasks
Driving Success
Prioritise Client Experience
Behaviours
Energy
Passion
Respect for others
Honest and Fair
Positive Attitude
Client Focus
Tenacity
Achieves Results
Ability to work independently and self-managed
Leadership
Demonstrate honesty and integrity
Strive for Client Centricity
Be agile and have the ability to adapt to change
Build relationships and trust
Be an agent of change
Collaborative
Ability to work in team orientated environment, and also to work independently and self-managed
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