To read, interpret and understand the Rule Summaries, Clinical Requests and Implementations Requests, decide how best to action it and then to accurately action it.
Duties and Responsibilities
Maintenance and control of data bases
Maintain (capture into and perform clean ups) and control accurate data on the systems (Cerm, ASPO) used by MK namely:
- Ensure the correct data is on the nappi files so that Nappi files can be distributed to clients:
- Distribution of product files to clients- medical schemes, computer vendors, paying offices etc.
- Distribution of public domain files to BHF and other clients.
Correctly load the Medical Scheme Data onto the system by:
- Collection of Medical Scheme information relating to financial and processing rules from Implementation Department/Implementation form.
- Read, understand and interpret this information so as to decide the best way to load the data plus the impact of this new data on the existing data
- Loading of this information onto relevant databases (CERM and ASPO)
- Creation of reports for self-checking
- Submission of these reports to Quality Assurance department for sign off
- Work with the all departments to resolve incidents and queries as and when incidents arise. Incidents are to be resolved as quickly as is possible.
Capture and update Service Provider data by:
- Receipt of information (e.g. terminations or change in bank details) regarding providers from BHF and Legal/Contracts department.
- Maintenance of provider networks, billing groups and payment groups, vendor groups received from schemes, USAP, payment houses and vendors.
- Maintenance of vendor information received from computer vendors.
- Maintenance of network rules.
- Creation of reports and checking of these reports.
- Collection of information from pharmacies on pharmacy detail changes and the loading of this information.
Maintenance of Cardholder file by:
- Ensuring the receipt and transfer of daily cardholder files from the Medical schemes onto the Medikredit System
- Receipt of error messages on the cardholder files and the follow up on these errors with the medical schemes.
- Liaise with marketing and schemes regarding problems.
- Loading of cardholder validation rules on relevant databases.(Cerm and AS400)
- Loading card holder anomalies off anomalies report
- Ensuring receipt of WHO ATC updates annually
- Ensuring receipts of Tariff files and change circulars throughout the year and the manual updates of these files on the MK database.
- Ensuring the receipt and loading of weekly BHF files with the service provider details
- Ensuring the receipt of quarterly HPC and SAPC files To review and maintain knowledge of SLA’s relating to the Quality Control department deliverables ensuring that the SLA are complied with and where not, are escalated immediately to the customer.
- If there are error, to manage and drive the incident process ensuring all incidents are resolved within agreed timelines. Incidents are to be analysed for the identification of trends so that appropriate improvement areas and training requirements can be identified.
- To ensure that compliance to all Inter-department and External SOP’s is met. All deviations being escalated and approved by the manager.
- To ensure that monitoring and operationalization takes place on all implementation, incident, adhoc and project related changes.
Project participation and management:
- To take an active role in all projects/Adhocs/implementation/incidents affecting data admin, reviewing all areas of responsibility thoroughly, actively participating throughout projects at the meetings to ensure no data admin aspect is overlooked.
- Review all project/Adhocs/implementation/incidents related documentation to give appropriate feedback timeously to the Project Manager/Business Owner and OIM Manager, ensuring all aspects of the data admin department have been considered
- To proactively identify the Data Admin requirements and deliverables per project/Adhoc/implementation/incidents, ensuring no project/Adhoc/implementation/incidents is delayed due to non-identification or non-delivery as per agreed timelines.
- To ensure appropriate operationalization of a product, customisation or project within and across departments relating to a Data Admin Work with areas and customers to ensure an error free and seamless implementation, acting proactively on errors to minimise impact to Medikredit and customer.
- To identify and arrange for appropriate and timeous training of information relating to a project/Adhocs/implementation/incidents..
- To proactively identify the need for an adhoc, submitting a detailed adhoc, negotiate timelines based on priority and drive the adhoc to completion.
- Proactively update SOPs based on business impact prior to screen dumps / code releases to review and finally update with screen changes not holding back any process for lack of self-identified SOP changes.
Customer Support:
- Establish and maintain sound relationships with clients, Implementations department, providers, vendors and marketing by:
- Responding to and taking responsibility for requests politely and proving feedback on status as per the agreed SOP/departmental practice
- Contacting clients or providers telephonically to check on or remedy discrepancies
- Being proactive in sourcing information
- Responding to all requests for queries ( internal) within the agreed timelines/SLA’s
Continuous Improvement:
- Use internal analysis reports’ information to identify trends applicable to the company or the Data Admin department.
- Using these reports to identify areas for improvement and training requirements.
- Utilising existing control reports and reporting tools plus identifying new control reports, to review the global picture relating to the Data Admin process as opposed to reviewing files/changes in isolation. (seeing the bigger picture) also seeing/anticipating the possible interrelationship between changes.
- To use the information to identify inadequacies and implement continuous improvement ideas.
- To use the information to identify training requirements for the Data admin department.
- To drive to conclusion the Training that has been identified (i.e. to ensure that the Training does occur).
Documentation and Administration:
- Ensure that all documentation requirements related to Data Administration from Providers is in the agreed format and within the agreed time lines
- Ensure that all departmental administration requirements are met as per the company policies and procedures
- Drive and take responsibility so that all max discussions take place as per the agreed time lines
- Ensure that all company SOP’s and SLA’s are complied with
- Draft and continuously update as required any SOP’s that must be written in the areas of delegated ownership
- Ensure that all daily workflow stats are updated on the logs and submitted to the Data Administration Manager/Data Administration Team Leader as per the agreed timelines
- Team support and development
- Work effectively and cooperatively with colleagues by establishing and maintaining good working relationships.
- Participate in multi skilling by either taking responsibility for one’s own development and be open to feedback on how your performance is viewed or by providing timely coaching, guidance and feedback to colleagues when sharing and up skilling their knowledge
Educational Requirements:
- Matric certificate/ Grade 12
- A relevant tertiary qualification will be an advantage
Background Experience:
- Previous experience working with Medical Scheme rules is essential
- Knowledge of MediKredit systems a distinct advantage
Work Requirements:
- The position is based in Sunninghill
The Employment Equity approach of Universal Healthcare broadly aims to:
- Foster diversity in the workplace;
- Promote equal opportunity and fair treatment in employment through the elimination of all forms of unfair discrimination.
Desired Skills:
- Good knowledge of MS office
- Ability to apply logic to the capturing of implementations is essential
- Accuracy in capturing
- Investigative skills
About The Employer:
Universal Healthcare has established itself as a leader in providing evidence-based, integrated healthcare services in the areas of medical scheme administration, healthcare insurance, healthcare management, corporate and occupational health and wellness, and integrated wellness-based loyalty programmes.
We create access to healthcare for the people of South Africa through medical schemes, customised corporate health products, health insurance, employee wellness programmes, managed care, a network of healthcare professionals, gap cover and much more.
Employer & Job Benefits:
- Provident Fund
- Group Life and Permanent Health Insurance
- 360 Degrees Loyalty Programme