MANAGED CARE QUALITY AND PROCESS SPECIALIST at MEDICAL SCHEME

About the position

The Managed Care Quality and Process Specialist will be responsible for overseeing and improving the quality and efficiency of managed care operations
The role involves analysing current processes, developing strategies for improvement and ensuring compliance with industry standards
The Specialist will work closely with various department to implement best proctives and enhance service delivery

The candidate will serve as a Quality and Process Specialist, with a strong emphasis on aligning internal quality processes and standard operating procedures within Managed Care

PURPOSE OF THE JOB

• Develop and implement quality improvement initiatives to enhance managed care services
• Monitor and evaluate the effectiveness of current processes and identify areas for improvement
• Conduct regular assessments to ensure compliance with industry standards and regulations
• Analyse existing workflows and processes to identify inefficiencies
• Design and implement process improvements to streamline operations and improve service delivery and outcomes.
• Collaborate with cross-functional teams to ensure seamless integration of new processes
• Prepare comprehensive reports for team leaders and management, highlighting key findings and recommendations.
• Utilize data to drive decision-making and strategic planning
• Provide training and support to staff on quality improvement initiatives and new processes
• Develop educational materials and plan workshops to promote best practices
• Foster a culture of continuous improvement and excellence within Managed care
• Address and resolve any issues or concerns related to managed care quality and processes.
• Monitor member and provider satisfaction levels
• Implement initiatives to improve the member and provider experience.

KEY PERFORMANCE AREAS

• Conduct and document quality assurance activities with Managed Care, serving as an internal quality and process specialist
• Upskill the managed care team
• Share findings and transfer best practices and knowlege to enhance team performance
• Assist in reviewing internal processes and current quality procedures
• Independently and cooperatively review standard operating procedures and processes within Manged Care
• Review, evaluate and report findings
• Asses current query trends against existing standard operating procedures
• Analyse and provide feedback/recommendations on monthly operational quality assurance reports, including escalations and CMS queries/complaints
• Ensure regulatory compliance

QUALIFICATION AND EXPERIENCE

• A relevant degree/diploma
• Minimum 3-5 years experience in quality assurance, process improvement within the Medical Aid industry
• Sound knowlege of Managed Healthcare is essential

Desired Skills:

• DEGREE/DIPLOMA
• MANAGED HEALTHCARE EXPERIENCE
• 3-5 YEARS EXPERIENCE IN QUALITY ASSURANCE AND PROCESS IMPROVEMENT
• EXPERIENCE WITHIN THE MEDICAL AID INDUSTRY IS ESSENTIAL