Scope of Responsibility:
• Assist in the continuous improvement of comprehensive wellness/disease management programmes.
• To develop a method and agree with the funder/employer on how to manage and operationalise beneficiary disease registrations and reimbursement.
• Analyse clinical, utilisation, and other data of members and healthcare providers.
• Share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.
• Identify trends in utilisation, fraud, and other factors.
• Ensure efficient Customer Service and compliance to agreed SLA’s.
• Manage and maintain data integrity and update accordingly where necessary.
• Provide input and/or develop other processes to manage utilisation more efficiently.
• Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
• Regularly review all approved claims and ensure that all are settled according to correct tariffs and Nappi codes.
• Supply monthly management reports.
• Maintain the chronic medication benefit rules, registration, and compliance reporting.
• Ensure an optimal interface with the PBM provider to facilitate beneficiary registrations for listed chronic medicine programs.
• Coordinate services by contracted providers to deliver annual wellness screenings and services for example health days.
• Liaise with enrolled members to ensure adequate funding and compliance to a Care-map.
• Any other duties as assigned by your supervisor from time to time.
Qualifications:
• Matric
• Registered Pharmacy Assistant
• Valid membership of the South African Pharmacy Council
• Claims and Forensic Risk management certification (will be an advantage)
Skills and Experience:
• At least 5 years’ experience as a registered Pharmacy Assistant.
• Sound understanding of the South African Health Industry, benefits, options, etc
• MIP Application System experience and advantage.
• Ability to liaise with external parties – clinicians and members
• ICD codes, modifiers, and RPL tariff knowledge and understanding.
• Ability to liaise with external parties – clinicians and members.
• Ability to work within an established team.
• Excellent oral and written communication skills.
• Customer-centric attitude.
• Excellent analytical skills and pays attention to detail.
• Computer literate - MS Office suite, i.e. Word, Excel.
• A good understanding of claims risk profiling.
• Experience in claims auditing.
• Good understanding of evidence-based medicine principles and embracing health economic principles and tools.
• A good understanding of the principles of healthcare funding design will be an advantage.
