Council For Medical Schemes jobs

Introduction

Through our client-facing brands Metropolitan and Momentum, 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. Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.

Disclaimer

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

Role Purpose

Provide quick and accurate resolution of client complaints according to policy, procedures, legislative / compliance requirements and within Service Level Agreements.

Requirements

Qualification

• Matric Qualification ( Essential)
• Relevant degree or diploma in a clinical field (advantageous).

Experience

• More than 3 years' of experience preferably in a similar position within the medical aid industry.

Skills

• Excellent written skills
• Intermediate computer skills, Microsoft Office.
• Ability to maintain co-operative working relationships.

Knowledge

• Thorough knowledge of claims processing.
• Comprehensive knowledge of the interpretation and application of the various industry bodies, i.e. Board of Healthcare Funders (BHF), Occupational Therapy
• Strong knowledge of hospital operations advantageous (case management, billing, etc.).
• Occupational Therapy Association of South Africa (OTASA), Council for Medical Schemes (CMS), etc.

Duties & Responsibilities

• To efficiently manage and co-ordinate existing and potential relationships between Scheme, Service Providers and Momentum Health (MH).
• To provide accurate and efficient service to MH, Scheme, Members and Service Providers.
• To ensure that exemplary services are rendered at all times to Scheme Management, Service Providers and existing Scheme members.
• To ensure that MH renders all services to the Scheme in accordance with the Service Levels and Standards as set out in the service agreements.
• To identify enhancements to the service delivery and administration, and to promote these enhancements to the MH Management Team and Service Providers.
• To provide an appropriate level of technical advice and support regarding Scheme issues.
• To assist the Scheme, Service Providers and MH with high level queries and complaints.
• Responsibilities include:
  • Classification of complaints ( General , Media , Principal officer(PO), Council for Medical Scheme(CMS) ).
  • Detailed Investigation of complaints.
  • Routing of complaints to various SPN.
  • Drafting final written responses to Complainant and Scheme.
  • Perform root cause analysis (RCA) and identify mitigation.
  • Identify trends and training needs emanating from RCA.
  • Assist Managers to efficiently manage and control the supporting system and Scheme Rules.
  • Manage workflow and production (Service Level) for complaints.
  • Liaising between MH/Scheme/Service Providers and Members.

CLIENT

• Build and maintain relationships with clients and internal and external stakeholders.
• Deliver on service level agreements applicable to 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.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
• Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

PEOPLE

• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
• Take ownership for driving career development.

FINANCE

• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
• Identify solutions to enhance cost effectiveness and increase operational efficiency.
• Implement and provide input into governance processes, systems and legislation within area of specialisation.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes
• Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.

Competencies