Claims Risk Analyst

SUMMARY:
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POSITION INFO:

Position: Claims Risk Analyst Vereeniging

Position Purpose: Analyse data and identify trends and patterns relating to inappropriate billing from providers and hospital networks, systems related issues and possible training gaps.

5 - 6 years Clinical experience in Medical and Managed Care environment, advanced knowledge of clinical coding essential.

Experience: Good knowledge of medical terminology, clinical documentation, computer paper-based data - or

management, and knowledge of the SAMA billing and hospital billing rules

Qualifications: Nursing Diploma or extensive experience in assessing and clinical coding

Continuous improvement - Analyse data and identify trends and patterns relating to inappropriate billing from providers - Analyse data and identify trends and patterns relating to ResQ calls and prioritize queues according to risk factor and impact across assessing areas - Prepare comprehensive reports on irregularities identified and forward to line manager - Identify loopholes that increase risk to the organisation and propose solutions - Implement practical solutions that use the specialist and departmental systems and processes - Undertake critical business analysis including the investigation, scoping and development of data applications and reporting standards - Engage with queries and data issues and follow the query resolution process until fully resolved - Ensure that data and information is verified and valid - Perform regular spot checks to ensure required data quality levels and standards are maintained - Update data on system, include relevant scheme information and distribute to stakeholders - Implement and maintain a risk identification system - Monitor and test controls for risk mitigation

- Implement practical solutions that use the specialist and departmental systems and processes

- Provide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisation

- Identify problems and develop and propose solutions to present to appropriate leader or stakeholders - Ensure day to day operational support required from area of specialisation is provided to enhance performance

Cost containment - Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisation

- Continuously review cost / benefit and Return on Investment within area of specialisation

Drive customer-centricity - Maintain a high level of impact on other departments to support improved delivery

- Continually increase understanding of client and stakeholder needs, satisfaction and service delivery

Knowledge management - Ensure that adequate knowledge regarding specialisation is shared as required and maintained within the research library

- Provide advice and / or training as required

- Maintain, develop and implement specialist knowledge within the day to day operations of the organisation

Maintain expertise level - Be a member of related professional bodies

- Ensure CPD (continual professional development) or similar accreditation requirements are met annually to ensure maintained specialist accreditation

Network key relationships - Engage with and provide support to the established network of internal and external expert resources and partners

Specialist support to projects - Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when required

- Conform to project management disciplines when participating in projects

- Represent department or project on appropriate committees related to area of specialisation

Continuous improvement

- - Analyse data and identify trends and patterns relating to inappropriate billing from providers - Analyse data and identify trends and patterns relating to ResQ calls and prioritize queues according to risk factor and impact across assessing areas - Prepare comprehensive reports on irregularities identified and forward to line manager - Identify loopholes that increase risk to the organisation and propose solutions - Implement practical solutions that use the specialist and departmental systems and processes - Undertake critical business analysis including the investigation, scoping and development of data applications and reporting standards - Engage with queries and data issues and follow the query resolution process until fully resolved - Ensure that data and information is verified and valid - Perform regular spot checks to ensure required data quality levels and standards are maintained - Update data on system, include relevant scheme information and distribute to stakeholders - Implement and maintain a risk identification system - Monitor and test controls for risk mitigation

- Implement practical solutions that use the specialist and departmental systems and processes

- Provide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisation

- Identify problems and develop and propose solutions to present to appropriate leader or stakeholders - Ensure day to day operational support required from area of specialisation is provided to enhance performance

Cost containment

- Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisation

- Continuously review cost / benefit and Return on Investment within area of specialisation

Drive customer-centricity

- Maintain a high level of impact on other departments to support improved delivery

- Continually increase understanding of client and stakeholder needs, satisfaction and service delivery

Knowledge management

- Ensure that adequate knowledge regarding specialisation is shared as required and maintained within the research library

- Provide advice and / or training as required

- Maintain, develop and implement specialist knowledge within the day to day operations of the organisation

Maintain expertise level

- Be a member of related professional bodies

- Ensure CPD (continual professional development) or similar accreditation requirements are met annually to ensure maintained specialist accreditation

Network key relationships

- Engage with and provide support to the established network of internal and external expert resources and partners

Specialist support to projects

- Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when required

- Conform to project management disciplines when participating in projects

- Represent department or project on appropriate committees related to area of specialisation

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