Vereeniging: Claims Risk Analyst

Browse Jobs in Vereeniging
Browse Jobs in Emfuleni
Browse It Computing Software Jobs

Job Summary

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

Claims Risk Analyst position available in Emfuleni, Vereeniging. This job position was posted by . The job has been posted on 2024-07-07 in the It Computing Software category

Click Go Apply to apply online!

You might also like to look at the available jobs in the same area.

Here are some more related positions