Overview
Claims Team Leader Jobs in Gaborone, Botswana at Momentum Group Limited
Title: Claims Team Leader
Company: Momentum Group Limited
Location: Gaborone, Botswana
Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organizations’ care for and reward their employees and members.
Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.
Role Purpose
Lead and manage the claims team to ensure claims are processed accurately, appropriately, and in compliance with scheme rules, clinical protocols, tariffs, and fraud prevention measures while supporting cost containment and service excellence.
Requirements
- Tertiary qualification in the field of health (Nursing, MBCHB, B.Pharm, B Cur)
- Registration with relevant regulatory body determined by qualification
- 4 – 6 years’ experience in Claims management (essential)
- 1 – 2 years’ people management experience (essential)
- Experience in the insurance / related industry (essential)
Duties & Responsibilities
INTERNAL PROCESS
- Oversee claims processing to ensure compliance with scheme rules, tariffs, clinical guidelines, and policies
- Manage, monitor and control the Claims team’s delivery on Service Level Agreements made with clients.
- Manage, monitor and control the team’s execution of client claims and queries.
- Act as an escalation point to assist Claims team addressing client queries.
- Review and reconcile claims payable reports and address discrepancies timeously.
- Monitor outstanding claims liabilities and support month-end payable reconciliation processes.
- Oversee the auditing of medical claims for accuracy and appropriateness
- Review high-risk, complex, or high-value claims
- Escalate fraud or abuse concerns for investigation and support recovery initiatives and provider audits
- Analyse the Claims Administration processes and identify opportunities for improvements; implement improvements within the Claims team.
- Identify and report process and system failures and enhancements to improve client experience.
CLIENT
- Continuously monitor turnaround times and quality standards, manage client query processes, and provide regular reports on the delivery of services against agreed service level agreements and in terms of overall client targets.
- Provide authoritative expertise and advice to clients and stakeholders, build and maintain relationships, negotiate and deliver on service level agreements, and make recommendations to improve client service and fair treatment of clients within the area of responsibility.
- Understand client needs and member risk profiles to develop and deliver tailored healthcare solutions and services.
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service
PEOPLE
- Create a positive work climate and culture to energise employees, demonstrate exemplary leadership behaviour, and select and recruit suitably qualified talent in line with employment equity principles.
- Drive a culture that guides and directs best practices, enables a learning and growth culture, executes effective workforce planning practices, identifies employee growth and development needs, manages performance, and encourages innovation, change agility, and collaboration within the team.
- Continuously develop own expertise in terms of professional, industry and legislation knowledge
- Take ownership for driving career development
FINANCE
- Improved control over claims liabilities and outstanding payments
- Support accurate financial reporting and reconciliation processes
- Contribute to the financial planning process within area
- Identify opportunities to enhance cost effectiveness and increase operational efficiency
- Manage financial and other company resources under your control with due respect
- Provide input into the risk identification processes and communicate recommendations in the appropriate forum
Competencies
- Adopting Practical Approaches
- Generating Ideas
- Developing Strategies
- Making Decisions
- Directing People
- Empowering Individuals
- Upholding Standards
- Producing Output
