Job Description

To manage medical benefit utilization through supervision of pre-authorization answer queries over the phone and give timely solutions to the customer.

The following key outputs are required from this role.

• Pre-Authorization of all admissions within 6 hours and technical guidelines.
• Minimize identifiable cases of fraud/abuse
• To resolve customer queries over the phone and offer solutions to the customers in a timely manner
• Supervise Pre-authorization of scheduled and non-scheduled admissions within the set guidelines and carry out verification and medical Audit of claims/invoices before settlement.
• Managing requests for services from providers, intermediaries and clients, providing information on the UAP Old Mutual provider network and available benefits per scheme policy
• In conjunction with SMART applications resolve card issues raised at the point of service
• Authorization of all optical requests from the different providers within 6 hours and prepare daily reports
• To attend to reimbursements from the different providers in a timely manner and provide daily reports.
• Liaise with other medical schemes for purposes of evaluating medical risk.
• To formulate committal letters of discharges as a result of the requests from the different service providers.
• Responsible for ensuring adherence to, implementation of, and adoption of Compliance, Anti-Money Laundering (AML), and Sanctions-related policies, procedures, and process requirements within Old Mutual and its subsidiaries. This includes execution of customer due diligence processes, ensuring compliance with Know-Your-Customer (KYC) standards, conducting ongoing and enhanced due diligence, and maintaining data quality. Additionally, the role involves identifying and monitoring potential AML, Sanctions, or Compliance breaches and unusual activities, and escalating these concerns to the Risk and Compliance Office for further action.
• Any other duties as maybe assigned.

Skills

Action Planning, Action Planning, Authentication, Computer Literacy, Contract Administration, Contract Management, Customer Complaint Management, Customer Due Diligence (CDD), Daily Reporting, Data Compilation, Due Diligence, Enhanced Due Diligence, Ensure Compliance, Evaluating Information, Information Retrieval, Invoices, Know Your Customer (KYC), Management Reporting, Negotiation, Numerical Aptitude, Oral Communications, People Management, Point of Service, Reimbursement, Report Review {+ 3 more}

Competencies

Action Oriented

Collaborates

Communicates Effectively

Courage

Cultivates Innovation

Customer Focus

Decision Quality

Manages Complexity

Education

Bachelors Degree (B): Nursing (Required), Diploma (Dip): Nursing (Required)