Job Title : Medical Claims Supervisor ALS
Sector Title : Insurance
Area : Johannesburg
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As per contracts requirements EMS claims adjudication process and platform requires that there is presence of an ALS practitioner who carries the highest level of certification in prehospital patient management ALS critical care EMS claims including Aeromedical flight claims cannot be adjudicated by a lower level certified practitioner as they would clearly be practicing out of scope and cannot challenge administration of any drugs or equipment used which is out of level and scope of their practice
Key Responsibilities
Resolve any technical or contentious EMS claims within the boundaries of medical knowledge Medical Schemes Act and Health Professions Council of SA protocols
Management and review of medical reports PRFs invoices and clinical motivations
Identifying clinically justified reasons why full payment of invoiced EMS claim may not be made and managing of responses to SPs on all Reprised and Rejected EMS claims
Handling any SP complaints associated with a claims adjudication and management
Manage and develop the internal and external relationships which allow the claims function to operate effectively and efficiently
Providing effective efficient and professional service to service provider practitioners both telephonically and through written correspondence
Co Coordinating of training of Service Providers in invoicing and billing on request
Ensuring self and team adherence to organizational best practice and legislative requirements
Fraud detection and reporting
Investigate all questionable claims
Analyze information gathered by investigation
Prepare report of findings of investigations and make recommendations
Collect and keep evidence record to support contested claims
Ensuring all risks are mitigated and escalated this includes the identification of fraudulent activities EMS benefit waste and abuse
Interview and correspond with service provider agents to address and rectify errors or omissions to EMS claims
Refer questionable claims to the SP Manager for lodging with the schemes&rsquo forensic investigators
Report questionable prehospital patient management to the Health Professions Council of South Africa and to the SP Manager for lodging with the schemes forensic investigators
Trend analysis &ndash outlined areas and hot spots medical conditions for which claims are lodged high and unusual utilizations agent behavior
Cost Containment
Accurately assess cost contain audit invoices and manage EMS claims received and to settle them in accordance to liability including communicating all decisions to the services providers effectively and accurately
Ensure quality of clinical and logistical adjudication of EMS claims in line with internal and client cost containment measures and strategies
Compiling of biweekly and monthly cost containment reports
Process Management
Making suggestions as to how the total system can be improved and identifying process improvement opportunities
Update system case notes timely with approval status and final decisions on all critical care EMS claims assessed including Aeromedical flights
Provide feedback to Claims Manager and or SP Manager of any errors recorded or identified with suggestions for improvement
Actively participate in regular claims team meetings and interdepartmental meetings ie EMS Contact Centre Medical Travel Contact Centre
Ensure that the team strictly adheres to SOP and that processes meet the required audit standards and comply with Council of Medical Schemes legislation and Health Professions Council of SA protocols
Staff Support and Supervision
Support team with difficult queries tasks and complex calculations
Daily monitoring of productivity & stats volumes agent behavior systems issues etc
Management Support
Provide support and assistance to the Claims and SP Manager
Provide medical and clinical support and assistance to other functions within the business as and when required by Management
Requirements
Minimum of 1 year working experience in an Emergency Call Centre
ALS qualification
Fluent in English and Afrikaans or English and Ethnic languages
Good knowledge of geography
Analytical ability and problemsolving skills
Ability to keep a cool head when dealing with difficult clients
Ability to manage time and tasks
Positive warm friendly approach
Ability to work independently punctual reliable and productive
Emotionally stable and able to work under pressure
Salary Market related
Please forward updated resume in MS Word with your application Note if no correspondence is received within 6 weeks of your application please consider your application as unsuccessful