The Quality Assurance Manager - Health will oversee quality audits of medical claims, enforce claims cost controls, identify process and knowledge gaps, and design/remedy action plans.
Key Tasks & Responsibilities
Quality Audits Of Claims
- Conduct an 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.
- Review the integration exception report between E02 and D365.
Trending Analysis & Claims Processing
- Enforce claims cost controls, e.g., copayments, discounts, provider restrictions, waiting periods.
- Monitor and ensure compliance with SOPs for claims, case, and provider management.
- Manage reserve philosophy for admission/ approval and enhanced amounts.
- Review IP bills for scheduled cases on a monthly basis.
- Reimbursement reports review to pick exceptions and cold calling/impromptu visits.
Training & Process Development
- 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 the implementation of said actions.
Reporting
- 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.
Systems Enhancement
- Continuously review the effectiveness of workflow systems and recommend enhancements.
- Provide input on ML and core system enhancements to improve quality and output.
- Monitor risk management activities: GIA issues, root cause and close out.
- Prepare regular claims reports to management and advise the underwriter on relevant claims findings for medical risk review.
Dispute Resolution & Management
- 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
- Aligns Execution - Planning and prioritizing work to meet commitments aligned with organizational goals.
- Manages Complexity - Making sense of complex, high volume and sometimes contradictory information to solve problems effectively.
- Builds Effective Teams - Building strong-identity teams that apply diverse skills and perspectives to achieve common goals.
- Ensures Accountability - Holding self and others accountable for meeting commitments.
- Business Insight - Applying knowledge of business and the marketplace.
- Strategic Vision - Seeing ahead to future possibilities.
- Drives Results - Consistently achieving results under tough circumstances.
- Customer Focus - Providing cautious, timely, and helpful service.
- Engages & Inspires - Creating a climate in which people are motivated to do their best.
- Instils Trust - Gaining trust through honesty, integrity, and authenticity.
- Cultivates Innovation - Creating new ways for the organization to succeed.
- Develops Talent - Developing staff capabilities.
- Bio-statistics skills
Requirements & Qualifications
- Bachelor's degree in Healthcare Administration, Nursing, or a related field.
- Relevant certifications in healthcare management or clinical operations are preferred.
- Minimum of 5 years of experience in clinical operations, claims processing, or a related field.
- In-depth knowledge of Quality Assurance, claims processing, and regulatory requirements.
How to Apply
Interested and qualified? Go to Old Mutual Workday Job Portal to submit your application.
