Job Details of Medical Benefits Officer

Job Purpose: Job Purpose:
Support the Manager in network management, medical governance, audits and ad hoc project work across the department to ensure adherence to company policies, standard operating procedures and regulatory authorities’ mandates. In all areas, maximise the use of automation to limit company expense and improve efficiency.
Ensure that Medical Benefits (MB) policy and procedures are upheld in all operational activity. Administrate projects, scheme updates and process revisions in line with MB objectives and management direction ensuring accurate documentation of process and policy change in line with audit parameters. Support management reporting with reports and dashboards.



Job Accountabilities:

• Support claims, pre-approvals and customer support teams across medical and administrative operations to ensure they are operated effectively within the MB team thereby ensuring consistency. Work with the Manager to identify and monitor quality and establish problem areas and implement corrective action.
• Maintain a consistent business process review approach making maximum use of automation to improve speed and quality of internal processes and the customer experience.
Compile feedback from various sources thereby measuring external medical providers and healthcare benefits, documenting and investigating to seek recommendations for quality improvements.
• 
  
  

Specific to Medical Governance

• Support the Manager in managing and controlling risk by monitoring compliance within Medical Benefits using statistical trends and analysis.
• Research medical evidence-based guidelines to ensure appropriate controls and consistency in policy application (pre-approvals, appeals and claims adjudication).
• Support the Manager in defining medical requirements and ensure appropriateness of contracted providers, specialties and specialists in line with the network strategy and the provider contract management team.
• Liaise with external providers relating to all medical and technical aspects as per established contracts in order to ensure that the service provided is in accordance with the requirements. This will include assisting the Manager with service quality audits on providers as per agreed protocols focusing on concerns around potential fraud and abuse.
• Monitor the medical and insurance regulatory environment, understand potential implications for the Group and manage initiatives to ensure compliance, e.g. disease management programme.

Qualifications & Experience: Qualifications:
Degree or Honours (12+3 or equivalent) in a relevant business field with relevant experience (medical insurance HR policy, projects etc.)

Experience:
2+ yrs

Knowledge/skills:
Knowledge of claim examination procedures and standard insurance procedures.
Knowledge of medical terminology is desirable.
Knowledge of company insurance schemes and the reimbursement and benefits system would be an advantage.
Proficient in written and spoken English.
Computer literate and proficient in the MS Office Suite of Software with advanced Excel skills.
Preferred knowledge of web based tools such as SharePoint and Business Intelligence