Query Resolution Team Leader

Role Purpose Accountable for the day to day operations relative to the overall management of escalated and resolution of queries regarding claim related issues.

Minimum Requirements

• Completed Degree OR currently studying toward a relevant Degree is essential.
• At least 10 years of Experience in the medical aid environment
• Minimum 3–5 years proven leadership or management experience
• Has held a management position dealing with staff for at least 5 years
• 5 years with in the claims and claims query processing area
• 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
• Business Acumen - Understands how the business operates, what the key issues and risks are that drives business success; and how they impact on the commercial viability of potential ventures and the profitability of the Group.
• Client Commitment - Anticipates, meets and exceeds client’s needs by creating long lasting relationships that support the client value proposition, supports their financial wellness and ensures client centricity.
• Drive for Results - Drive a sense of urgency, focus, accountability, agility and execution to deliver business results.
• Leads Change and Innovation - Actively leads change, does what is right for the business and drives continuous improvement through innovation.
• Motivating and Inspiring Team - Creates and maintains an open, positive working environment by generating commitment, building trust, a shared sense of purpose, empowerment in others and encouraging them to contribute to the best of their ability.
• Collaboration - Prioritises the business interests of Momentum Metropolitan and invests in the success of the group by aligning effort across divisions.
• Impact and Influence - Persuades, convinces, influences and inspires others, both within Momentum Health and externally to win support, loyalty and gain commitment to the purpose of Momenum Health.
• Self-Awareness and Insight - Manages self and relationships with others effectively and provides perspective in difficult situations.
• Diversity and Inclusiveness - Is sensitive to individual and cultural similarities and differences and demonstrates humility and an openness to engage people from diverse backgrounds and cultures to the mutual benefit of all parties concerned.
• Growing Talent - Takes responsibility for own development; and actively mentors, coaches and develops talent in others. Builds leadership bench strength for MMI by providing opportunities and 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
• Minutes of meetings/projects
• Investigation of high level escalations –providing feedback to management
• Assisting the provider network department in regard to providers escalation that may require recon
• Stale claim analysis and report feedback
• Managing the pathology credit process.
• Liaising with the finance department in regard certain debt processes
• 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
• Manage weekly discipline reports
• Complete performance reviews
• Ensure accuracy of claims payment
• Provide authoritative, expertise and advice to clients and stakeholders
• Build and maintain relationships with clients and internal and external stakeholders
• Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments
• Define service practices which builds rewarding relationships, encourages innovation and allows others to provide exceptional client service.
• 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.
• Create a positive work climate and culture to energise employees, give meaning to work, minimise work disruption and maximise employee productivity.
• Demonstrate exemplary leadership behaviour, through personal involvement, commitment and dedication in support of organisational values.
• Select and recruit suitably qualified talent in line with Employment Equity principles and MMI values
• Drive a culture that guides and directs best practice, fostering an environment of continuous learning, improvement and cohesiveness.
• Enable a learning and growth culture whereby information regarding successes, issues, trends and ideas are actively shared between team members.
• Execute effective workforce planning practices to ensure that staffing Responsibilities Internal Process Enhancements to processes and systems
• Competencies Business Acumen - Understands how the business operates, what the key issues and risks are that drives business success; and how they impact on the commercial viability of potential ventures and the profitability of the Group.
• Growing Talent - Takes responsibility for own development; and actively mentors, coaches and develops talent in others. Builds leadership bench strength for MMI by providing opportunities and Duties & Responsibilities Internal Process
• Enhancements to processes and systems
• Enable client centricity within area of responsibility
• (Client Services)
• Effectively lead team
• Execute effective workforce planning practices to ensure that staffing Responsibilities Internal Process
• Execute effective workforce planning practices to ensure that staffing
• in the medical aid environment

Responsibilities

• Enhancements to processes and systems
• Creates and updates process documents related to process and audit processes and the sharing of these documents
• Minutes of meetings/projects
• Investigation of high level escalations –providing feedback to management
• Assisting the provider network department in regard to providers escalation that may require recon
• Stale claim analysis and report feedback
• Managing the pathology credit process.
• Liaising with the finance department in regard certain debt processes
• 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
• Manage weekly discipline reports
• Complete performance reviews
• Ensure accuracy of claims payment
• Provide authoritative, expertise and advice to clients and stakeholders
• Build and maintain relationships with clients and internal and external stakeholders
• Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments
• Define service practices which builds rewarding relationships, encourages innovation and allows others to provide exceptional client service.
• 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.
• Create a positive work climate and culture to energise employees, give meaning to work, minimise work disruption and maximise employee productivity.
• Demonstrate exemplary leadership behaviour, through personal involvement, commitment and dedication in support of organisational values.
• Select and recruit suitably qualified talent in line with Employment Equity principles and MMI values
• Drive a culture that guides and directs best practice, fostering an environment of continuous learning, improvement and cohesiveness.
• Enable a learning and growth culture whereby information regarding successes, issues, trends and ideas are actively shared between team members.
• Execute effective workforce planning practices to ensure that staffing Responsibilities Internal Process Enhancements to processes and systems
• Internal Process
• Enable client centricity within area of responsibility
• (Client Services)
• Effectively lead team
• Execute effective workforce planning practices to ensure that staffing Responsibilities Internal Process
• Execute effective workforce planning practices to ensure that staffing