Internal Process
- Perform administrative duties and provide a professional service to members, where special grantsare requested in cases where medical expenditure, in excess of the Scheme's limits, has caused and or wouldcause financial hardship for members.
- Establish and maintain knowledge of Ex Gratia Guidelines and mandates, Scheme Rules, Benefit Exclusionsand Claims operational systems.
- Process all documentation received from members, service providers, Managed Care Service providers andthe Scheme or Principal Officer accurately and timeously and confidentially.
- Record and assesses the Ex gratia Application Form and supporting documentation for completeness.
- Makes telephonic contact with the member to acknowledge receipt of the form.
- In the event of an incomplete Ex gratia Applications and/or outstanding supporting documentation, request the member to send the outstanding documents.
- Perform claims investigation and reconciliations to ensure that all claims are processed correctly, and refer to Claims department for correction where necessary.
- Refer applications to the relevant managed care organisation (MCOs) for validations where applicable.
- Cancel the Ex gratia application as per standard operating procedure (SOP), should the requested information not be received.
- Accurately investigate and prepare Ex Gratia cases for presentation by the Ex Gratia Manager to the Ex Gratia Committee, comprising of the Scheme's Board of Trustees and the Scheme officials.
- Educate and guide members regarding their benefits to enhance understanding and satisfaction with their benefit options.
- Take ownership of escalated and unresolved queries and ensure they are resolved timeously and effectively.
- Ensure the effective, accurate and timeous completion of relevant documentation accompanying applications.
- Provide clear communication to all parties involved in an investigation with regards to the outcomes and process.
- Ensure Service Level Agreements are met and exceeded.
- Maintain high standard of quality ensuring all cases are prepared accurately.
- Provide and maintain accurate and thorough telephonic information to members, service providers and Business Partners regarding queries for claims and general client services relating to Ex Gratia.
- Finalise and communicate meeting outcomes for members and draft outcome letters.
Client
- Build and maintain relationships with clients and internal and external stakeholders.
- Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed.
- Make recommendations to improve client service and fair treatment of clients within area of responsibility.
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
- Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
- Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
- Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.
People
- Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
- Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
- Positively influence and manage change and offer specialist support where required.
- Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
- Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
- Take ownership for driving career development.
Finance
- Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
- Identify solutions to enhance cost effectiveness and increase operational efficiency.
- Implement and provide input into governance processes, systems and legislation within area of specialisation.
- Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes.
- Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.
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