Conduct audit of overall claims settled, placing special attention to high value, repeated visits, and duplicate claims. Check error rate.
Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagements issues on billing.
At the end stage of provider reconciliation, claims that relate to benefit excesses are to be reviewed and liability assigned to either UAP, client / scheme or Smart.
Admissions tracking; checking on exaggerated bills, unnecessary admissions or overstay admissions, doctors’ charges.
Review integration exception report between E02 and d365.
Review system rejections of claims.

Conduct trending analysis; identify leakage; and prepare objective reports on claims and case processing processes

Enforce claims cost controls e.g. copayments, discounts, provider restrictions, waiting periods
Monitor and ensure compliance to SOPs for claims, case and provider management
Manage reserve philosophy for admission/ approval and enhanced amounts. Review IP bills for scheduled cases monthly.
Reimbursement reports review to pick exceptions and cold calling/impromptu visit.

Contribute to the development of process-specific, competency-based trainings;

Identify knowledge gaps and training needs of the claims, case team
Identify gaps in policy terms and review together with the retention team.
From the findings of the audit of IP and OP settled claims, give recommendations and remedial actions. And drive implementation of said actions

Prepare reports to communicate outcomes of quality activities

Monitor and share reports of TATs for all key claims processes
Track claims paid in E02 vs D365; use of the exception reports to monitor paid, reversed and cancelled claims

monitor risk management activities: GIA issues

Prepare regular claims reports to management and advice underwriter health on relevant claims findings for medical risk review.
Root cause and close out

Systems Enhancement

Continuously review the effectiveness of workflow systems and recommend enhancement.

Resolve difficult client enquiries:

ensure timely completion of investigations/resolution arising from claims disputes in case management and claims teams.
Investigate suspected fraud issues; guide the fraud reporting to GFS and follow up to closure.
coach, counsel or train less-experienced staff; provide input in the performance management, goal setting and review processes.

Skills And Competencies

Knowledge & Experience

Qualifications