Talent Pool : Configuration Specialist MMH

Role Purpose

Responsible for configuring the O2 System accurately as well timely implementation and maintenance of critical information. Ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements. Administers and maintains the platform for all schemes and insurances that are currently administered by Momentum Health to ensure that admin and Managed Care components are up to date to ensure that the Momentum Health Schemes and Insurance products are functioning as per the design intent accurately and efficiently.

• Matric or Grade 12
• Associated Degree or equivalent combination of education and experience
• 5 to 7 years Healthcare experience
• In depth medical aid industry knowledge - Essential
• A good understanding of how medical aid administration operates (including and not limited to the benefit structure and medical terminology) - Essential
• Good knowledge of file formats and reporting tools - Advantageous
• Good knowledge of tariffs and the government gazette – Essential

• Analyze and interpret data to determine appropriate configuration changes.
• Accurately interprets specific Scheme benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.
• Validates coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.
• Apply previous experience and knowledge to verify accuracy of updates to claim/encounter and/or system update(s) as necessary.
• Works with fluctuating volumes of work and is able to prioritize work to meet deadlines and needs of department.
• Reviews documentation regarding updates/changes to member enrolment, provider contract, provider demographic information, claim processing guidelines and/or, system configuration requirements. Evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core processing system (O2).
• Conducts audits on samples of processed transactions impacted by these updates/changes. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.
• Clearly documents the audit results and makes recommendations as necessary.
• Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 10 days of error issuance.
• Helps to evaluate the adjudication of claims using standard principles and specific policies and regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, over payments, and processing errors of claims.
• Prepares, tracks, and provides audit findings reports according to designated timelines
• Presents audit findings and makes recommendations to management for improvements based on audit results.
• Provides input from a system perspective, into the year- end process, new projects, system failures, file failures and claims errors.
• The escalation point for the business and IT.
• Investigates escalation regarding ERA”s to providers (electronic remittance advise )
• Provides the initial system set up for new schemes and options
• Updates and creates of tariffs, limits and rules on the on-line system - liaises with fund and provider negotiations,
• Updates and creates limits and templates, events and rules on the on-line system (includes update to modifiers, unit and rate table) liaises with Fund, Corporate Governance and auditors.
• Conducts claims testing to avoid financial loss to the business.
• Actions exceptions on Kr1s reports to ensure that the scheme/s are protected against possible losses by each change made on the live system.
• Generates, Analyses and communicates claims impact to the business, to ensure the most feasible decision is taken.
• Liaises with the business in terms of system impact, claims impact and feasibility of business requests.
• Participates with Scheme audit process with a zero audit finding result
• Documenting of Master files and other business related processes. Process improvements…