Claims Risk Analyst

Position: Claims Risk Analyst VereenigingPosition 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 - ormanagement, and knowledge of the SAMA billing and hospital billing rulesQualifications: Nursing Diploma or extensive experience in assessing and clinical codingContinuous 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 performanceCost 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 specialisationDrive 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 deliveryKnowledge 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 organisationMaintain 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 accreditationNetwork key relationships - Engage with and provide support to the established network of internal and external expert resources and partnersSpecialist 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