Junior Bookkeeper

Industry: Pharmaceutical Benefit Management

Reference Number: CWR.MS.BDPP

DESCRIPTION: Our client is a South African pharmaceutical benefits management (PBM) organization and specializes in electronic claims processing and the management of medicine benefits.

They are looking for a Benefit Design Pharmacist to join their team.

JOB DESCRIPTION: Ensure the accurate processing of medicine claims in accordance with client specifications, optimizing benefit design strategies to improve patient outcomes, cost efficiency, and compliance with regulatory standards.

This role also contributes to the continuous improvement of medicine management processes and systems to enhance efficiency and effectiveness.

MAIN DUTIES & RESPONSIBILITIES:

1. Claims processing and medicine management rules
2. Assist both Mediscor clients and Mediscor internal departments with resolving claims queries related to medicine management rules.
3. Implement medicine management rules for electronic claims processing, for new and existing clients, on the various Mediscor platforms according to predetermined specifications.
4. Compile and update documentation of all medicine claims processing rules, and communicate the changes to all relevant stakeholders.
5. Test and approve all medicine claims processing rules to ensure predetermined specifications are met.
6. Co-ordinate and implement year-end roll-over changes for medicine claims processing rules for existing clients on the Mediscor platforms, meeting deadlines according to the roll-over schedule and predetermined specifications.
7. Monitoring the accuracy of medicine rules
8. Monitor the Mediscor retro-active rule audit system (Pythagoras) daily and make the necessary changes to ensure the accurate pricing of medicine claims.
9. Monitor the Mediscor pro-active rule audit system (QA) daily and make the necessary changes to ensure the accurate processing of medicine claims in the claims database.
10. Liaise and meet with clients and provide guidance and advice regarding medicine benefit design and medicine claims management at least once per annum.
11. Ensure that escalated queries are resolved timeously.
12. Systems and Process Enhancement
13. Identify areas for improvement in systems and processes that can be implemented to ensure the accurate and timeous processing of medicine claims.
14. Assist IT to test the claims platforms during software upgrades to ensure claims processing isn't negatively affected by the software upgrades.

EDUCATIONAL REQUIREMENTS:

1. Grade 12
2. B.Pharm Degree
3. Registered with the SA Pharmacy Council

EXPERIENCE AND SKILLS REQUIRED:

1. Minimum 3 years experience in the health care or medical aid industry or Retail / Courier pharmacy experience.
2. Microsoft Office; including Excel, Word, and PowerPoint at the intermediate level.
3. Project Management.
4. Sound knowledge of Drug Utilization Review.
5. Knowledge of the medical scheme and managed care industry.
6. Sound knowledge of the pharmacy / pharmaceutical industry.
7. Good knowledge of various legislation concerning medical schemes, health insurance, PMBs, and other healthcare issues.
8. Excellent verbal and written communication skills.
9. Analytical and detail oriented.
10. Interpersonal and customer-oriented service skills.
11. Ability to work independently and in a multidisciplinary project team.
12. Handle pressure and difficult situations.
13. Be able to work under set deadlines; time management is critical.
14. Be responsible and able to maintain confidentiality.